A birth centre's encounters with discourses of childbirth: how resistance led to innovation
Address for correspondence: Denis Walsh, Department of Midwifery Studies, Faculty of Health, University of Central Lancashire, Preston PR1 2HE
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.
A feature of maternity services as we enter the 21st century is the presence of a number of contrasting discourses, each seeking to promote their particular orthodoxy. Natural childbirth competes with medically managed birth for women's hearts and minds (Fox and Warts 1999). Paternalistic and patriarchal structures line up against feminist ways of doing (Treichler 1990), and Davis-Floyd (2001) cites three overlapping but distinct models of care that are vying for influence: the technocratic, the humanistic and the holistic. She discusses the principal values that underpin each of these models, concluding that ‘contemporary obstetrical practitioners have a unique opportunity to weave together elements of each paradigm to create the most effective system of care ever designed on this planet’ (p.21). Other paradigms, however, tend to vilify the technocratic or biomedical model for its hegemonic and exclusive knowledge claims. As Rolfe (2001) explains, a fundamental tenant of positivism, the theoretical perspective underpinning biomedicine, is its claim to objectivity that renders other epistemologies invalid. Alternative discourses allow for the legitimacy of their competitors, even though they may fundamentally disagree with what they espouse. Given this fundamental difference, it is difficult to envisage the realisation of the synergy that Davis-Floyd calls for.
This paper adopts a Foucauldian view of discourse which seeks to identify the power dynamics inherent within them. In particular, it articulates their use of authority (Foucault 1973). As Jordan (1993) comments, this authority may not be rationally deducible or intuitively evident but it is self-validating, either because it is forwarded by powerful interests, or because it represents an orthodox way of ‘doing’. It marginalises alternative understandings or approaches simply because they represent a challenge to the status quo. For Foucault, every discourse is premised on a power agenda and therefore none is immune from an intolerance of difference. With this reading, feminist, humanist and holistic discourses, though claiming to be open systems, may also seek to exclude. Foucault understood that the power of discourses operated through inscription – their ability to write subjectivities onto those who enter their sphere of influence and therefore regulate behaviour, for example individuals becoming ‘model patients’ when encountering biomedicine.
The paper discusses two prominent healthcare discourses – the biomedical model and the professional/client relationship, currently impinging on current maternity care by examining findings from an ethnographic study of a free-standing birth centre (FSBC). These discourses were not named by the birth centre staff or the women clients and are clearly my interpretation of their narratives. However, I believe they resonate with the reflexive posture of the staff and women as they encountered over time what for them were powerful orthodoxies of ‘how things were done’. Though these discourses are presented here as having strong regulatory and disciplinary effects, successful resistance that creates other options in the care encounter is apparent in the birth centre data. Drawing on Fox's (1999) postmodern social theory of health, it will be argued that personal agency is not rendered passive by discourse but that new subjectivities are possible. Fox conceptualises this creating of space for new possibilities and potentials as ‘nomadic’ activity. I will explore the emergence of these new potentials in birth centre staff and the women using the facility. The discourses around the biomedical model and professional/patient relationship will be ‘deconstructed’ (to use Derrida's (1978) term) to make space for more holistic readings of childbirth events and ‘care as gift’ relationships (Fox 1999) between staff and clients. Finally, examples of dissonant data (data that are at odds with the prevailing direction of findings) will be discussed. These illustrate the fragility of discourse boundaries and suggest that a more complicated and multi-layered picture exists of discourse's intersection with individual agency and meaning-making.
Aims and method
The aim of the birth centre study was:
- – to explore the culture, beliefs, values, customs and practices around the birth process within a free-standing birth centre.
Ethnography, with its roots in cultural anthropology, has evolved as the appropriate method to examine culture. Helman (2003) describes ‘culture’ as a set of guidelines that individuals inherit and learn as members of a particular group. It ranges over knowledge, belief, customs, ideas, concepts, rules and meanings that underlie and are expressed in the way that humans live. What this description does not emphasise is any contested dimension to the understanding of ‘culture’. Many contemporary anthropologists would emphasise that culture exists in a constant state of change and that meanings consist of negotiated agreements (Hastrup 1995, Ferraro 2003). Because meaning systems involve relationships that are not essential and universal, different human societies will inevitably agree upon different relationships and meanings. The paper's understanding of culture acknowledges this sense of fluidity.
Setting, data collection and analysis
Free-standing birth centres cater for about one to two per cent of all United Kingdom births per year. They are funded centrally from the National Health Service (NHS) budget, and only women considered to be at low obstetric risk have access to them. All birth centres have a link maternity hospital (consultant unit) to which complications of childbirth are transferred if they arise. The birth centre was situated in the midlands of England and catered for the births of around 300 women a year. It was sited within a small district hospital with the nearest consultant maternity unit 15 miles away. It was staffed by midwives and maternity care assistants (MCAs) who provided a 24-hour service. There were three birth rooms and capacity for five postnatal women. After gaining ethics approval for the study, participant observation was undertaken over a nine-month period and included all hours of the day and all days of the week. In addition, an opportunistic sample of 30 women was interviewed approximately three months after giving birth at the centre. Thirteen of these were nulliparous and 17 multiparous. Of the 13 women having their first baby, seven gave birth at the centre and six were transferred to a consultant unit either prior to labour or during labour. Five of the 17 multiparous women were also transferred to a consultant unit. Six of these had previously given birth at the centre. Therefore, 19 out of the full sample of 30 women actually gave birth at the centre. Six of the 30 women had been born at the centre themselves. All of the women had partners and all were of white European ethnic origin. Though the sample was selected opportunistically, it was in line with the local community profile of women accessing the centre. They were fairly typical of birth centre clients internationally which are known to come disproportionally from white, middle-class backgrounds (Walsh and Downe 2004). A purposive sample of 10 midwives and five MCAs, representing a breadth of clinical experience, were also interviewed.
All interviews and field notes were recorded and transcribed. Analysis in ethnography happens concurrently with data collection. This dialectical interaction between data collection and analysis requires the researcher carefully to consider both activities simultaneously while maintaining an open orientation to new data. A tension is therefore often created between emerging theory and fresh data that may endorse, refine, challenge or contradict it. For the ethnographer, reflexive skills are pushed to the limit as the focus of a study can change dramatically from first intentions. As Hammersley and Atkinson (1995) pithily comment: ‘this requires the exercise of some analytical nerve, tolerating uncertainty and ambiguity in one's interpretations and resisting the temptation to rush to determinate conclusions’ (1995: 210).
Reflexivity is fundamental to analytic integrity in ethnography and my own presuppositions about the findings were challenged early on in the data collection. Believing that the birth centre model was a haven for ‘active birth’ practices (women very mobile during labour, adopting upright postures for birth and taking charge of decision-making), early observations revealed women labouring on beds, birthing on beds with little expression of preference. A reflexive disposition required me to ‘let go’ of this focus and explore broader indicators of women's and staff priorities in this setting.
Before discussing the findings from the study, I will contextualise them against the backdrop of postmodernism and, in particular, Fox's postmodern theory of health.
The crisis of modernity has been expounded on at length within medical sociology (Bury 2000, Hyde and Roche-Reid 2004) and, within this writing, positivism, as the validator of knowledge within modernity, has been thoroughly critiqued (Smith 2002, Clark 1998). Despite this, the current evidence paradigm in healthcare resembles a metanarrative, characteristic of modernity, with its emphasis on the generalisability of positivistic research results. Voices arguing for a turn to contextual consideration in research application are beginning to be heard as clinicians and managers grapple with the difficulties of implementing even ‘proven’ healthcare interventions (Rycroft-Malone et al. 2004, Scott et al. 2003). These authors expound on the value of qualitative research in teasing out the meanings that health professionals assign to research results and which therefore affect how they practice.
In focusing on meaning, an engagement with postmodern thought begins as postmodernism is characterised by meaning-making and ‘little truths’ (Fox 1993). A diverse and eclectic philosophy, postmodernism emphasises the contingent, context specific, multi-layered and transient nature of knowledge, ever-changing as individuals negotiate a path of meaning through their lived experience. It emphasises the role of language in shaping knowledge, as language constructs the particular truth or meaning as understood by individuals in a particular time in a particular place.
The ambivalence and sometimes confusion this creates is illustrated by how the word ‘control’ has been understood in relation to childbirth. A number of the major players in maternity care have used this word to illustrate aspects of their agenda. In policy documents on childbirth services, ‘control’ has been understood as consumers exercising decision-making over choices and options during labour and birth (DOH 1993). ‘Control’ in feminist childbirth literature has been about addressing power differentials between patriarchal obstetrics and women's experience within the maternity services (Oakley 1992). ‘Control’ in consumer lobby groups commonly meant resisting the medicalisation of childbirth and the freedom to pursue natural, physiological birth (Kitzinger 1978). Finally, ‘control’ for women in a number of qualitative research studies of childbirth was paradoxically expressed as giving authority over to the childbirth professionals to manage the birth as they saw fit (Green 1999).
For the protagonists of postmodernism, it is outlook that is suffused with possibility and potential, that enriches life with difference and diversity. For the antagonist, it leads to uncertainty, instability and relativism. The sharp end of a postmodern take on discourse is its impact on individual agency. Foucault was pessimistic about a person's ability to resist discourse inscription and retain autonomy, describing bodies as docile (Foucault 1973). Fox (1992) takes a much more optimistic view of personal agency believing individuals can demonstrate resistance. His optimism resonates with empirical studies of maternity care where individual behaviours do sometimes challenge powerful orthodoxies of care (Walsh 1999, Esposito 1999). It is to his postmodern theory of health that I now turn.
Fox (2000) begins his exposition of a postmodern theory of health by offering three ‘promises’. The first promise is to open up the discourses that fabricate the body, releasing individuals from their inscriptions. The biomedical model as expressed in the medicalisation of childbirth and the traditional professional carer/caree relationship are the two discourses deconstructed here.
The second promise in Fox's postmodern theory of health is to engagement with the discourses. Though this engagement may manifest as resistance, it is typically not disciplinary or oppositional, which might have the effect of simply replacing one orthodoxy with another. It is creative and transforming, opening up space for difference and eclecticism to manifest itself. What seemed a remote possibility now becomes a real possibility and what was never previously considered becomes an option. The story detailed later of a woman going shopping in advanced labour is one such occurrence where the biomedical orthodoxies of labour progress and professional attendance at labour are subverted.
The third promise is to immediacy. There is no preparation, planning or training required for this engagement – just an openness in the present. This captures the sense of nomadic roaming, that responds to the present, dwells with the present, then moves on. A midwife's approach to caring for a teenage girl reflects this intuitive and immediate response to the present and is elaborated on later in this paper.
Fox (1999) adopts from the philosopher Deleuze and his colleague Guattari, who was a psychotherapist, the image of the nomad (Deleuze and Guattari 1988) to characterise the action of the agenic self as it negotiates a path within and between discourse. By resisting discourse inscription, ‘deterritorialising’ herself, she opens up space for other options and possibilities. In this paper, these opportunities are manifested in the approach to clinical care and in the personal relationships within the centre.
For Deleuze and Guattari, the nomad lived in the present, not bound by the past or burdened by the future and this sense of detachment allows for a more seamless passage through and between discourses while at the same time, paradoxically, facilitating engagement with them. This altered sense of temporality infuses the midwives’ interaction with women, freeing them from time-driven clinical imperatives around labour progress and releasing space and time for empathic and intuitive responses to women's behaviours.
‘Care as gift’
Fox (1999) in developing his postmodern theory of health pays special attention to the role of the carer vis-à-vis the ‘cared for’, and is critical of the professionalisation of caring. He sees this as another discourse (the ‘vigil of care’) inscribing the docile body with a subjectivity of being the recipient of care. Fox borrows from the post-structuralist feminist Cixous (1986) the idea of ‘proper relationships’ as pertaining to property and possession, as opposed to ‘gift relationships’ pertaining to generosity, agape, delight and curiosity. He juxtaposes the two in advocating a resistance to ‘vigil of care’ or ‘the proper’, and an embracing of ‘care as gift’. He suggests that those in the helping professions deconstruct the artificial boundaries imposed by theories of caring, and actively seek non-possessive, non-reciprocal, non-hierarchical relationships that find joy in giving and celebrating difference.
Departing from anthropological understandings of gift as transactional and reciprocal (Mauss 1954, Tyler and Taylor 1998), ‘care as gift’ does not expect anything in return. It is unconditional in the same way that Shaw (2003) conceptualised another aspect of childbirth – breastfeeding, as a gratuitous and unrequited act. Bolton (2000) explored similar domains in nursing where she likens nurses’ emotional work to gifting without expecting any return on investment, except the satisfaction they derive from being able to ‘make a difference’ (2000: 584). Care as gift has no agenda or programme apart from engaging and responding to the ‘other’ in the care encounter.
What follows from Fox's postmodern perspectives on health with its promises, ‘nomadism’ and care as gift dimensions is an orientation to celebrating difference, to inclusiveness as space is made between discourses and to generosity, as an openheartedness marks discourse encounters. Resistance to two discourses operating on the birth centre and the creativity that this resulted in, will now be detailed.
Resisting the biomedical model
Fox (1992) was able to demonstrate individual patient resistance in his analysis of the activity of hospital surgeons and, in particular, regarding discharge following elective surgery. The intersection of biomedicine's priorities (an uncomplicated post-operative recovery) with the patient's social domain (desire to return home as early as possible) resulted in a surgeon reframing a post-operative raised temperature as an anomalous and inconsequential finding. The patient goes home with the raised temperature discounted by the surgeon as a consequence of the recent surgery. Fox concludes that resistance can manifest and an individual can shed a compliant patient subjectivity, even in a scenario heavily inscribed by biomedicine's power.
The data from the birth centre study illustrated two areas where orthodoxies were resisted and usurped: women's reasons for booking at the birth centre and the care of a woman during an equivocal clinical episode.
Biomedicine holds the link between safety and place of birth as axiomatic (Tew 1998). Women encountered this safety imperative when visiting their GP in early pregnancy. Vivienne recalls:
I went to my GP and she said you will be going to the hospital to have the baby and I said why can't I go to the birth centre . . . and she said Oh! well we really wouldn't advise it. You do realize that there won't be any doctors present and, if anything goes wrong, they will have to take you to the hospital . . . (Transcript No. 18, p.7).
Linda related a similar incident with her GP:
Well, I think the doctors just made me feel that with your first you don't know what it will be like and it could be horrendous and you have got to get from the birth centre to the hospital. And I think they kind of scare you (Transcript No. 27, p.4).
In the context of childbirth, scientific evidence about mortality and morbidity has been assumed to be pivotal to women's considerations about where to have a baby (MIDIRS 2005) and safety has been a fundamental concern for policy makers (DOH 2002) and professionals (RCOG 1999). Yet women's reasons for choosing the birth centre for birth were an eclectic array of the social, practical and personal. Recommendations from family, friends and work colleagues were mentioned many times. These recommendations were based either on their own experiences having babies at the centre or stories retold about other people they knew. Monica was typical:
I had spoken to a family friend who had the last of her three daughters at the birth centre and she said that it was by far the best. She had the first two at neighbouring hospitals, you know, as you’re expected to do (Transcript No. 25, p.3).
Another woman found out about the centre through her work colleagues:
At business managers meetings, there were quite a few people who had babies in the last couple of years. Many had been to nearby hospitals but nobody who I had spoken to had got a bad version of the birth centre – they just said how lovely it was (Rose, Transcript No. 15, p.3).
Sometimes the influences were more rooted in family history as seven of the women had been born there themselves. As one woman said –‘I was born there and so were my brothers and sisters. Why would I want to go anywhere else?’ (Mary, Transcript No. 9, p.2).
The proximity of the unit to women's home, families and friends was a consideration:
Largely I wanted to go there because of my first child. I did not want to be too far away from home (Fay, Transcript No. 6, p.1).
This woman also said her husband, a local teacher, would be able to drop in at lunch time because he was literally five minutes walk away. One woman said her sole reason for booking there was the fact that the staff were comfortable with her teenage children being in the unit while she was in labour. She wanted them to be there immediately after the birth as they had expressed concerns about being marginalised by the arrival of the new baby. Finally, in one case it was the woman's partner who led the decision for the birth centre. His mother had recently died in the district general hospital where the larger maternity unit was based and he did not want to return there.
It was also clear in the interviews that women were aware of the nearby hospital as a ‘backup’ facility that might be needed from time to time:
It's there for the occasional complication (Mary, Transcript No. 9, p.3).
Elsewhere I have written about the significance of women's first visits to the birth centre where I theorise that women's intuitive and rapid appraisal of the birth environmental and emotional ambience constitutes a kind of nesting behaviour (Walsh 2006). Guaranteeing protection and privacy for offspring is central to mammalian nesting and it is interesting that woman describe the birth centre in language that clearly demarcates it from a hospital function. In interviews, phrases used included ‘like home’, ‘my bedroom’, ‘our living room’, ‘bed and breakfast’, a ‘small hotel’, and a ‘health farm’. This naming inverts the orthodox discourse of safety associated with medical personnel and infrastructure. For women having their first baby, the rhetoric of biomedical safety is especially powerful as noted by the general practitioners’ responses. Women, however, resisted the discourse's inscribing power, thus opening up the possibility of a fresh ‘take’ on safety, invoking social, familial and practical considerations.
These findings have resonance with Fox's (1999) elucidation of ‘promises’. The first promise (to open up the discourses that fabricate the body, releasing individuals from their inscriptions) is demonstrated by the women's encounters with their local doctors’ views of where they should have their babies and, after visiting the birth centre, their openness to that alternative.
The second promise is to creative engagement with the discourses that opens up space for difference and eclecticism to manifest. This was illustrated by a woman expecting her first baby who switched her booking from the consultant maternity hospital to the birth centre at 36 weeks. She had come from another country where birth was quite medicalised and there was a lot of private obstetric provision. She said:
I didn't consider the birth centre because I was nervous if anything went wrong. . . After I spoke to my community midwife then I started thinking about it that afternoon and thinking, ‘well, I've done all my care, all my appointments and everything has been there, all the way through my pregnancy. . . When I got to say to myself that just because it was small, it did not mean that it wasn't sort of professional, that changed my mind (Molly, Transcript No. 12, p.5).
In choosing the birth centre, women were aware that if complications developed, then transfer to a hospital was the appropriate course of action. In this sense, options were not held in oppositional terms.
The third promise (to immediacy) is reflected in the speed of decision-making of women when visiting the unit for the first time:
We went to have a look, and as soon as we walked in we thought – yep! This is the sort of place (Jasmine, Transcript No. 9, p.2).
These excerpts from women's interviews demonstrate successful resistance to biomedical orthodoxy around place of birth and the envisaging of an alternative meaning to safety.
The construction of risk and, in particular, of what constitutes appropriate referral criteria for transfer from birth centre to hospital, is another dimension of the biomedical discourse that is challenged by the study findings. Biomedicine has traditionally brokered these criteria (Kirkham 2004).
I was observing care on a night shift and had just witnessed a waterbirth. About one hour after the birth, the woman (Sarah) asked the midwife to come and see her. The field note continues:
She got really acute contraction-like pains. They were so bad that they made her go cold, clammy and faint and sick feeling when they came. Jenny (midwife) massages a bit of blood out of her uterus, not much, but it was pretty well contracted after that, but she really felt poorly when she got these contractions. Her vital signs weren't too bad. Her pulse was a little bit fast but blood pressure okay. Jenny managed it by just sort of cradling the woman in her arms, resting her head on her lap and holding it gently and massaging her hair and scalp in a very sort of motherly, maternal way. And she did that for a long time, 20–30 minutes. Just sort of held her safe I suppose, holding her in a comforting, caring pose (Observation No. 14, p.4).
Sarah settled and slept for the rest of the night. I had the opportunity to ask her about this incident when I interviewed her three months after the birth. She told me that she had felt very faint in the days following the birth and had passed a large clot vaginally during this period. I asked if her haemoglobin level was taken and she replied ‘Yes. It was 7.1.’ Clearly she had sustained significant intra-uterine bleeding in the early postnatal period. Many hospital-based midwives would probably have summoned a doctor to review her condition, either the night of the bleed or in the days that followed. It had crossed my mind that she might have had a ruptured uterus and I recognised in myself ‘worst case scenario thinking’– imagining the most extreme complication, regardless of clinical features. This I interpreted as a legacy of hospital-based midwifery practice over many years, despite the fact that I pictured myself as philosophically committed to birth as a normal physiological process. I was challenged by the midwife's non-clinical approach to the situation. She had made an assessment and had decided that it did not need any clinical intervention so she just held Sarah in an embrace. She clearly had a high threshold for judging whether pathology was developing in the situation. In other words, she was not ‘expecting trouble’, a phrase used by Strong (2000) in his stinging critique of interventionist antenatal care in the USA. Strong argued that this mindset turned women's experience of antenatal care into an anxiety-provoking nine months of uncertainty.
When I asked the birth centre's lead midwife about this episode, she explained the birth centre midwives’ normative mindset this way:
I think you have to look at the numbers of problems that have occurred postnatally through the unit and you keep the likelihood of it being something serious at the back your mind. And that's where it is, at the back of your mind and not the forefront (Kerry, Transcript No. 45, p.18).
Kerry's comment draws an important distinction between an approach that is anticipating normality and the biomedical paradigm. Her thinking, that ‘you keep the likelihood of it being something serious at the back your mind . . . and not the forefront’, contrasts with the ‘expecting trouble’ paradigm and Brody and Thompson's (1981) classic description of the biomedical model's approach to labour care as a ‘maximum strategy’ (to treat every birth as a potential disaster regardless of its predilection to that possibility). Such approaches foster interventionist obstetrics (Wagner 1994) and are probably major contributing factors towards the medicalisation of childbirth over recent decades (Johanson et al. 2002).
Hodnett et al. (2005) appear to support the classic biomedical position in the well-known systematic review of the safety of hospital birth centres versus consultant maternity hospitals, concluding that:
Just as an over-enthusiastic focus on risk and intervention can lead to unnecessary interventions and avoidable complications for healthy childbearing women and their fetuses (in hospitals), an over-emphasis on normality may lead to delayed recognition of or action regarding complications [in birth centres] (2005: p.4).
It may, however, be that it is precisely the fact that the possibility of complications resides at the back of birth centre staff's minds and not the front that makes a difference in this setting. Birth centres are noted for their low intervention rates and this perspective, coupled with a belief in the fundamental normality of childbirth, may increase the likelihood of achieving normal birth and decreases the likelihood of inappropriate transfer.
Many maternity units would probably advise a blood transfusion for the fall in haemoglobin level and for Sarah's symptoms. The staff gave her a choice of transferring to the host consultant unit for a transfusion, or staying at the birth centre where treatment would consist of oral iron supplementation and an iron-rich diet. Despite her symptoms, she opted to stay at the birth centre. Over the course of the next week, she regained her strength and was eventually discharged home 10 days after the birth. Her evaluation of the staff response to these events was unequivocally positive:
She [midwife] was great afterwards because it was like having my Mum there. I remember having my head on her lap and she was just stroking the back of my head saying you will be all right. Just kind of nursing you which was invaluable. It was like you were her daughter. I was so glad that they did not transfer me. I absolutely wanted to stay at the birth centre and I wanted to correct the anaemia myself, by dietary means primarily.
This example of discourse resistance and the options it created is also striking for its support of Sarah's personal agency and leads to consideration of another discourse: the professional/client relationship.
Resisting the ‘vigil of care’
Fox (2000) argues that traditional medicine supports a reading of this discourse as a ‘vigil of care’ and, as already discussed, posits ‘care as gift’ as a liberating alternative. His ideas have some resonance in the maternity care context with the writings on the midwife/mother relationship. Kirkham (2000), among others, has understood this relationship as somewhat distinct from other health care professional/client alliances. This distinction has been premised on unique features like its biologically determined longevity, its continuity through a major rites of passage experience, the intimate nature of its focus and the wellness status of most of the women undertaking the journey. Therefore descriptors of the relationship have emphasised equality, partnership (Pairman 2000), solidarity, skilled companionship (Page 1995) and the ‘professional as friend’ (Walsh 1999). Despite these descriptors, organisational methods of working have frustrated midwives’ attempts to realise their potential as they struggle to establish continuity in a fragmented service and to be advocates for women within a system that they feel oppressed by (Ball et al. 2003).
The fact that labour and birth services are structured around a predominantly obstetric model has also undermined midwife/women relationships. Machin and Scamell (1997) found that women previously orientated to non-interventionist, self-directed birth, submitted to an interventionist package as they encountered the ‘irresistible biomedical metaphor’ during labour. Midwives were the mediator of that package. Deference and paternalism marked women's response to midwives in Bluff and Holloway's study (1994) where the phrase ‘they know best’ was frequently used by women. Equality, partnership and authentic choice for women is a chimera within a system of professional dominance.
Midwives’ own belief systems heavily influence how they relate with women and can lead to ‘gently steering’ women to make choices the midwives want them to make (Levy 1999) or to agreeing to women's requests for home birth but then proceed to do a ‘hospital birth at home’ (Edwards 2000).
All these behaviours could be classified as having ‘vigil of care’ characteristics (Fox 2000) and are a disciplining of the care relationship, hedging it round with conditions and caveats that disempower women. Stories from the life of the birth centre stand out as different precisely because they demonstrate a reversal of this – a giving up of power by midwives and an expression of genuine agency by women, as Sarah experienced.
The midwife's intervention with Sarah was to nurture her, holding her in a matrescent embrace. She is resisting an imperative ‘to act’ which Fox (1999) aligns with the vigil of care. Physically to embrace and hold taps the more postmodern relational and intuitive domains, rather than the modernist and instrumental rational. Her care was highly appreciated by the woman for its personal support, respect of her agency and its avoidance of transfer.
Another episode of care illustrates how choices widen as care as gift is enacted:
It was the week before Christmas and I had one lady who was five centimetres when she came in. Actually she was really more six but she was desperate to get her Christmas shopping done – you know she had this little window of time to do it and now this! So because the labour wasn't that strong she decided she would return to her shopping and come back afterwards. She came back and delivered a couple of hours later. . . I was still here when she came back and she got her shopping done and then she went home that night after the baby was born. You have got to be flexible here (Gerry, midwife, Transcript No. 31, p.2).
Once a woman comes into a hospital in established labour, she is kept under constant surveillance. A clinical imperative (to ensure labour is progressing at an acceptable rate (O'Driscoll and Meager 1986)), an organisational imperative (to ensure she moves seamlessly through the hospital labour spaces (Perkins 2004)) and a professional imperative (to ensure she complies with clinician's instructions/advice [Anderson 2004]) drive this requirement. Here, as Gerry describes, all three imperatives are subverted. The expression of agency is related to a tangential issue – the need to complete the Christmas shopping – but which impacts on the labour because of the multiple responsibilities the woman carries. This is acknowledged by the midwife who gives her space to consider what would not normally be in the frame: returning to a supermarket in advanced labour. Care as gift is realised here because the midwife demonstrates unconditional and non-reciprocal giving. She has resisted the normative professional discourse which inscribes both herself and the woman with appropriate roles for this scenario. Concomitantly, the woman sheds a normative patient subjectivity in asserting the option to leave the birth centre and return to her shopping.
Another example of resisting the vigil of care was a woman's request to be without a midwife in the birth room even though she was in the second stage of labour. Both the midwife and the woman eschew their respective subjectivities (a professional ethic of the constant midwifery presence until the birth) and open up space for difference.
One begins to glimpse Fox's attributes of care as gift in these encounters: trust, confidence, generosity, admiration, allegiance. Care as gift found poignant expression in a midwife's response to a distressed teenager who came into the birth centre in early labour:
She was thrashing around on the bed so we took the bed out. Bev (the midwife) wondered whether her distress was due to the awesome responsibility of parenthood that she felt she wasn't ready for so Bev asked her Mum and her sister to leave the room. Then she just sat with her for two hours on the floor and this girl was just sobbing into her lap, just sobbing, and then after two hours – almost as if it was out of her system – she was completely more focused and she went on and had a really good birth (Transcript No. 45, p.7).
Here is an engagement that eschews ‘doing to’ for ‘being with’. The ‘doing to’ in maternity hospitals would probably have involved administering some analgesia to relieve the pain. Such an act confirms the ordering of professional care as task-mediated, discrete and temporally-bounded. No such restrictions applied in this story. It was an open-ended interaction as the midwife could not have known that they would be on the floor for two hours. Her disposition is not to task but to engagement and connection, what Fox calls a ‘responsibility to otherness’. She literally makes space (on the floor) for the girl to express herself until she is ready to move on. There is no formula here and to codify the midwife's response to the girl would be to re-cloak both in discourse. It's as if she says:
Here's some space for you . . go for it . . get on with it . . I trust and have confidence in you . . take my generosity of spirit (Fox 2000: 37).
Other attributes of care as gift are in evidence in another episode, though this time to do with the birth centre staff. Sharon (MCA) told the following story:
The girls here have been marvellous to me I have to say. Problems that I have had at home with elderly relatives dying of cancer. I've had a load of hassle and they have been really good. I've come in on nights and been knackered, not had any sleep and they have tucked me up in bed for a couple of hours. They ask how you are, ring you up even when they are not on duty. Yes, I love this place – it has been really good to me (Transcript No. 41, p.13).
Love and commitment are demonstrated in an inversion of the normal disciplining of the vigil of care. Sleeping on duty would be unacceptable in most healthcare settings but here it is an outworking of compassion for a staff member going through a crisis. This demonstration of altruistic, non-reciprocal giving, directed towards the staff, serves to confirm the authenticity and integrity of its expression in their relationships with the women.
Nomadic birth centre activity
A final dimension of Fox's postmodern theory of health has to do with the metaphor of the nomad. Because nomadic activity often occurs on the margins of discourse and can manifest itself as resistance to discourse, it is sometimes the cause of ‘disarticulation’. This is the term used by Davis-Floyd (2003) to explain the tension at the interface between discourses, in her case between natural homebirth and medical hospital birth in rural Mexico. Her research of midwives’ experience of transferring women from home to hospital when complications arose uncovered the hostility they encountered from hospital staff. Their midwifery knowledge was discounted and dismissed by the hospital, even when their advice would have led to a better outcome. These margins are the sites of greatest contestation as Gerry [midwife] alludes to in her interview in my birth centre study:
I'm getting better at it now [labour transfers] but they [the consultant hospital staff] do give you the impression that you’re dumping your rubbish on them (Transcript No. 31, p.4).
Birth centre care's invisibility is a liability here because the occasions when common labour interventions are avoided by intuitive care and when normal births occur against the odds, are not disseminated to host consultant hospitals. They remain hidden in the woman's narrative and in the birth centre's history, precisely because they did not trigger a ‘rescue’ from the hospital. This is unlike the reverse situation where poor outcomes following transfer out of a birth centre are usually subjected to severe scrutiny and appraisal by the host unit, and can result in pressure to close birth centres (Walsh 2004). The birth centre staff have to straddle alternative childbirth discourses at this intersection and Fox's figure of the nomad is particularly apposite, as they negotiate a path between them.
Fox is quick to make the point that the space between discourses where nomadic care resides is constantly exposed to colonisation from new and rival discourses. Hence, the temptation to reify birth centre care and birth centre relationships as novel examples of midwifery/women empowerment or a social model of care. There is a sense that once these ways of being/doing are named, expounded on and theorised, they become what they sought to resist – a discourse of knowledge that erects its own boundaries. For the birth centre staff the challenge is to engage with women in a non-possessive way, that respects difference and diversity. Slippage into disciplining patterns can arise when discourses previously discarded by the staff are apparently re-presented by women and represent dissonant data. The following example concerns a woman coming to the birth centre in early labour. She was on her second pregnancy and felt she could accurately interpret her body's signals. She continues:
This labour started exactly like last time. Spent a long time not doing an awful lot. Then she (the baby) just decided it's time. And the birth centre staff did not really believe me. I got comments like, ‘most of them stay at home at this stage and you’re not really in labour’. And I tried to tell her it was following the same sort of course but she wouldn't listen to me. . . She said to me, ‘have you just had a contraction?’ And I said, ‘yes I'm having one’. She said, ‘well they can't be that bad cause you’re talking to me’. I was quite glad when I got transferred to be honest (Lisa, Transcript No. 11, p.4).
Here the inscription was related to the acceptable response to early or latent phase of labour. Instead of acknowledging the possibility that this woman's physiology may be different, and agreeing to her staying at the centre rather than returning home, the staff try to inscribe the subjectivity of the normative birth centre practice for early labour. Lisa resists, stays at the centre awhile and then is transferred to the consultant maternity hospital. Her care at the hospital validates her decision to resist as the staff there accommodate her reading of events. She remains in the delivery suite and progresses to a normal birth within a few hours of arriving.
In another example of dissonant data, Cathy was in labour with her first baby. She goes on to describe her behaviour which seemed instinctive, but caused the birth centre staff concern:
I was being sick and I was like throwing myself on the floor like a dog because I was in that much pain and they were trying to get me on the bed because they thought it was dangerous. But I just kept getting back down again so they were putting cushions all over the floor. But then at that stage I decided to have the pethidine. But I had to have the pethidine on the bed and then they told me stay on the bed because . . but I couldn't, I couldn't stay on the bed. I had to keep walking (Transcript No. 3, p.2).
There are elements of wanting to control women's behaviour here, rather than to embrace what appears to be an instinctive response, which is perceived as deviant. Labouring women do not throw themselves onto the floor. A similar dynamic occurs after pethidine has been administered. The inscription – to stay on the bed – this time probably comes from a nursing orthodoxy that requires a patient to remain in bed after receiving an injectible narcotic. Both events demonstrate the ubiquity and power of discourse to define orthodoxy. This time the woman takes the initiative and successfully resists, creating space for alternatives. The midwives place cushions on the floor to accommodate her new subjectivity. In Fox's parlance, rejecting the use of a bed and throwing herself onto the floor was an expression of nomadic behaviour.
Discussion and conclusion
Findings from the birth centre study challenge prominent discourses of the biomedical model and the professional/client relationship that are common currency in contemporary maternity services. This is achieved by resisting, in Foucault's (1973) understanding, their inscribing power, thus opening up space for alternative readings and behaviours to manifest.
Women choose to give birth in the birth centre for an array of psychosocial and practical reasons, often using language that redefines the place of birth away from notions of hospital and medical infrastructure. In this way, the prevailing discourse around traditional notions of safety driving the choice for birth is usurped. Even more challenging is an example from the birth centre of a contrasting appraisal of clinical risk and of what constitutes a reason for obstetric referral. This appraisal seems to emanate from a ‘birth as normal physiology’ orientation which views complications as rare events, and exercises a correspondingly high threshold for their recognition.
Equally important in the episode was the demonstration of patient agency that was illustrative of a wider reconceptualising of the professional/client relationship within the birth centre. Using Fox's postmodern theory of health where he critiques the vigil of care discourse and proffers the alternative care as gift, I illustrate applications in stories from the birth centre. Interactions between the staff and women in these stories are characterised by spontaneity, non-reciprocal giving and egalitarianism. Traditional professional/client roles are discarded, making space for trust and generosity.
Activity of resisting discourse and living out of alternatives can be understood as nomadic. This metaphor captures both the detachment and engagement with discourse that is a key dynamic in the life of a birth centre. The dynamic has an element of tension as role inscriptions were resisted and new choices heralded steps into the unknown. It is not surprising that dissonance manifests itself from time to time where previous behaviour patterns re-emerge.
The stories of dissonance portray both the power and fragility of discourses. The tendency to codify new practices as successful, to generalise from them and the regression to former ways of doing/being highlights the unstable relationship between discourse, agency and meaning-making. A rich theme of literature supports this conclusion. Turner (2004) examined the professional paradoxes facing birth centre midwives in the USA whose occupational legitimacy rested on their professional status while, at the same time, the conferring of status by the biomedical/technocratic paradigm undermined the alternative practices they espoused at the birth centre. Foley and Fairclough (2003) studied midwives in Florida who practised from a holistic model of childbirth but constructed a narrative of medical collaboration to equate their work with that of physicians. Zadoroznyi (1999, 2001) in her Australian studies, emphasises the reflexive posture of women users of childbirth services who commit themselves to a natural/midwifery-mediated model of care but invoke biomedicine's interventions and technology at various junctures. Viisainen (2001), researching homebirths in Finland, found that natural birth had a variety of meanings for women and could even include medical interventions if women retained control over decision-making.
The most challenging of all may be Akrich and Pasveer's (2004) contention that a disembodied childbirth experience as a consequence of epidural anaesthesia or elective caesarean section can be as fulfilling (meaningful) as an embodied one (natural, physiological labour and birth) as long as women's agency is retained.
From these authors’ chequered accounts, the challenge for childbirth assistants is the positive engagement with discourses as they reveal themselves in the infinite variety of women's labours. This engagement can be resistance that opens up alternatives and options not previously in the frame or it can be ‘going with the flow’ of women's choices, even though they seem inscribed, and therefore controlled, by particular discourses. The engagement requires reflexivity to discern the play of power, sometimes subtly disguised within discourses but always present. It may also require a revisioning of relationships with women where the vigil of care is unmasked and discarded for a care as gift orientation. This navigation through discourse landscapes requires the detachment of the ‘nomad’ and is a ‘becoming’ rather than an ‘arriving’ disposition.
Fox (1999) suggests that nomadic care contributes to the ‘becoming of health’, beyond healthcare discourses. Midwifery theory may warm to its emancipatory, wholeness-orientated goals and be attracted to its deconstruction of dominant childbirth discourses, but there is little comfort here either for natural, normal or woman-centred projects of care, at least in the sense that they may attempt to control and conform childbirth to pre-determined templates. The birth centre lives with some tension around these ideas as the manifestations of dissonance indicate. Its philosophy may resonate more with the values of Davis-Floyd's (2001) holistic model, but it also prioritises women's choice and endorses women's agency.
Care as gift and nomadism as aspects of Fox's postmodern theory of health are true to their postmodern roots – they resist categorisation and reductionism but they still offer important insights in a healthcare environment strained between modernist certainties increasingly under threat and the sizable discomfort zone of postmodern ambiguity. Into this vacuum they bring promise of a better way of doing health and, for maternity care, of doing birth. This paper about birth centre care gives some tantalising glimpses of what that may look like.