The aim of this Professional Doctorate in Midwifery is to challenge the status quo in maternity services through scholarly reflection and research. Through the studies reported here I aim to provide women with information on which to make informed choices about the services available to them, and to ensure politicians become more responsive to the lack of options currently available in Australia. My aim is also to provide measures that would allow maternity service managers to deploy resources more efficiently to achieve the best care. The majority of the papers in the portfolio are derived from population data that is routinely collected in Australia. One of the cornerstones of healthcare improvement is creating meaningful information and measurement from these collections. True comparisons from accurate data can be used to better understand the nature of the system, and to gauge whether changes have been effective. Thus, the information derived from various collections of routinely collected data is used to measure and evaluate the maternity services. This measures only part of the experience of childbirth, however. The Doctorate is a collection of nine major works undertaken in the years 1999 to 2002, during my appointment as a research midwife with the Australian Midwifery Action Project (AMAP). The first paper is an essay that tells of the juxtaposition of two different worldviews and the paradigmatic issues that shape the professional differences between obstetrics and midwifery. The second consists of a brief overview of the Australian maternity system described within the terms of reference for a Senate Inquiry into Childbirth Procedures. The third and fourth papers explore the levels of obstetric intervention for low risk women and the cost of these interventions using a new costing model derived from population data. The fifth paper reviews the contemporary issues in the workforce and education of midwives. The sixth paper outlines a proposal for funding reform and a new model of midwifery care. The seventh paper compares midwifery in Australia and New Zealand, in terms of a public health strategy. The eighth paper explores the concept of a new research method called Graffiti; and the final paper continues the theme of measurement in an essay titled 'Evidence based Everything. The portfolio explores a number of issues around public funding and the call for reform of the maternity services in Australia. In particular it argues for reforms to fund a more responsive service, based on values outlined by women who experience maternity care in Australia, as opposed to those guided by obstetrics and technology who currently set the agenda and determine the way maternity services will be offered and funded. Although I have articulated and measured some of the characteristics of midwifery and obstetric care in Australia, this disentangling or quantification merely underlies and emphasises the many more continuations and complexities that coexist beyond that, which is 'measured'.

Midwifery care is often described as "woman-centred" and "empowering," yet the concrete or specific practices underlying this kind of care are not well understood. The study examined what midwives say and do in the process of care-giving during pregnancy, and how their care enhances clients' sense of personal competence and capability. Using qualitative methods, the researcher observed, recorded, transcribed and analyzed prenatal visits with nine midwives and their clients in Quebec birth centres. Findings revealed that relaxed conversation was a pivotal feature of the visits and primarily served the client's purposes. At multiple levels, the reciprocal, genuinely dialogic nature of the conversational process allowed the client to take charge and encouraged her to name her world. Educational aspects of care started with the client's agenda, assumed that she had expertise of her own, and affirmed that she could know and act for herself. The key characteristic of midwives' work was the communication of confidence in the essential normalcy of pregnancy and birth, and in the inherent strengths of women in these experiences.

The aim of this Professional Doctorate in Midwifery is to challenge the status quo in maternity services through scholarly reflection and research. Through the studies reported here I aim to provide women with information on which to make informed choices about the services available to them, and to ensure politicians become more responsive to the lack of options currently available in Australia. My aim is also to provide measures that would allow maternity service managers to deploy resources more efficiently to achieve the best care. The majority of the papers in the portfolio are derived from population data that is routinely collected in Australia. One of the cornerstones of healthcare improvement is creating meaningful information and measurement from these collections. True comparisons from accurate data can be used to better understand the nature of the system, and to gauge whether changes have been effective. Thus, the information derived from various collections of routinely collected data is used to measure and evaluate the maternity services. This measures only part of the experience of childbirth, however. The Doctorate is a collection of nine major works undertaken in the years 1999 to 2002, during my appointment as a research midwife with the Australian Midwifery Action Project (AMAP). The first paper is an essay that tells of the juxtaposition of two different worldviews and the paradigmatic issues that shape the professional differences between obstetrics and midwifery. The second consists of a brief overview of the Australian maternity system described within the terms of reference for a Senate Inquiry into Childbirth Procedures. The third and fourth papers explore the levels of obstetric intervention for low risk women and the cost of these interventions using a new costing model derived from population data. The fifth paper reviews the contemporary issues in the workforce and education of midwives. The sixth paper outlines a proposal for funding reform and a new model of midwifery care. The seventh paper compares midwifery in Australia and New Zealand, in terms of a public health strategy. The eighth paper explores the concept of a new research method called Graffiti; and the final paper continues the theme of measurement in an essay titled 'Evidence based Everything. The portfolio explores a number of issues around public funding and the call for reform of the maternity services in Australia. In particular it argues for reforms to fund a more responsive service, based on values outlined by women who experience maternity care in Australia, as opposed to those guided by obstetrics and technology who currently set the agenda and determine the way maternity services will be offered and funded. Although I have articulated and measured some of the characteristics of midwifery and obstetric care in Australia, this disentangling or quantification merely underlies and emphasises the many more continuations and complexities that coexist beyond that, which is 'measured'.

Thesis (MHSc--Health Science) -- Auckland University of Technology, 2005. / Also held in print (ix, 146 leaves, 30 cm.) in Akoranga Theses Collection. (T 618.36132 COW)

Thesis (Ph. D.)--University of Wisconsin--Madison, 1989. / Typescript. Vita. eContent provider-neutral record in process. Description based on print version record. Includes bibliographical references (leaves 495-515).

Childbirth, the biggest life event for a woman, is a complicated process. Childbirth pain not only involves physiological sensations, but also psychosocial and cultural factors. In addition, the way the woman handles the pain is affected by the meaning she attributes to it. In order to understand the experience of Hong Kong Chinese women in terms of childbirth in general and childbirth pain in particular, and to learn the meanings attributed, a longitudinal qualitative descriptive study was conducted with the aim of exploring the experience and meaning of pain in the context of childbirth for Hong Kong Chinese women. The study was informed by a systematic review and metasynthesis of existing relevant literature. Since people’s attitudes, beliefs and behaviours may change over a period of time, data were collected from the participants at 4 different time points: around 36 weeks of pregnancy; on postnatal day 3; 6-7 weeks after birth; and 10-12 months after birth. Purposive sampling was employed and a total of 10 Hong Kong Chinese women (5 primiparous and 5 multipararous women) were recruited for the study. The data were collected via semi-structured interviews, informed by phenomenological principles. The resulting data were described using thematic analysis The results from the metasynthesis together with the four interviews yielded 5 meta-themes: The cultural norms; The trajectory of pain sensation; Facing or escaping the pain; Someone to be with me; and Achievement and growth through the unforgettable experience. For these participants, satisfaction with their childbirth experience was not related to the pain they experienced, but to the care they received from their husbands and midwives, as well as to their own sense of achievement. Although the women remembered the fact of their pain over time, their affective noxious memories decreased as their concentration was on their Finally, the meta-themes were interpreted in the light of Maslow’s hierarchy of needs, and a model was proposed to help women to handle childbirth pain in the future.

This in-depth qualitative study considered how women from two different generations came to understand birth in the context of their own experience but also in the milieu of other women’s stories. For the purposes of this thesis the birth story (described as the ‘modern birth story’) encompassed personal oral stories as well as media and other representations of contemporary childbirth, all of which had the potential to elicit emotional responses and generate meaning in the interlocutor. The research utilised a hermeneutic phenomenological approach underpinned by the philosophies of Heidegger and Gadamer. This methodology allowed the significance of the experience of engaging with stories to be grasped, and in-depth insights into the meanings and lived experience for women of the phenomenon to be made. Twenty participants were purposively selected, recruited and interviewed. In phase one ten women who were expecting their first baby in 2013 were recruited in order to explore how they understood birth prior to the event and in the light of other women’s stories. Birth stories were revealed as one of many ‘voices’ offering ‘advice’ to women about birth. The women also talked about classes they had attended, books they had read, websites and online forums they had accessed, as well as television programmes and films they had watched. The conversations with the first cohort of women led to further questions about whether the information gleaned from media and virtual birth story mediums creates meaningful knowledge about birth for women. The second phase evolved from this thinking. In phase two interviews with an older cohort of women (who were pregnant in the 1970s –1980s) were undertaken to determine whether women from a different era were more able to translate knowledge into meaning. This was based on the belief that, for this 4 generation of women, stories were mediated by personal contact and not though virtual technologies as in the previous generation of women. Phenomenological conversations with the participants took place in the iterative circle of reading, writing and thinking. This revealed the experience of ‘being-in-the-world’ of birth for the two generations of women and the way of communicating within that world. From a Heideggerian perspective, the birth story was constructed through ‘idle talk’ (the taken for granted assumptions of how things are which come into being through language) and took place across a variety of media accessed by women, as well as through face to face conversations. Five central and interrelated interpretive findings emerged. Firstly the stories the women engaged with, had a significant role to play in their understanding and expectations of birth. The ‘norm’ as portrayed in the stories circulating in 2013, for instance, was one which perpetuated what one participant described as the ‘drama of birth’. Secondly, the modern ‘landscape’ of birth (populated with many media representations) created and perpetuated fear of childbirth for many of the women. The stories shared were lacking in detail about women’s lives, and did not necessarily help them to become ‘knowers’ and gain wisdom about birthing. Thirdly, the women birthing in the present day were overloaded with information amassed in an attempt to manage their anxieties about birth as well as to fit the role of the informed patient, and demonstrate their competency as mothers. Fourthly the cultural and spiritual significance of birth was not shared in the circulating stories in either generation. Finally, some of the birthing women felt secure in the ‘system’ of birth as constructed, portrayed and sustained in the stories widely circulated. The data revealed that the lifeworld of birth being sustained in stories (for both generations) was one of product and process, concentrating on the stages and 5 progression of labour and the birth of a healthy baby as the only significant outcome. Taken as a whole this thesis revealed that the information gleaned from birth stories did not in fact create meaningful knowledge and understanding about birth for these women. The study is unique in that no other published research has explicitly identified the premise of the ‘modern birth story’ or the notion of ‘idle talk’ in relation to childbirth. Further no other study has considered the phenomenon of engaging with these types of stories whilst pregnant. This study reveals how engaging with the ‘modern birth story’ and the ‘idle talk’ of birth may influence women’s expectations and consequent experience of birth.

The position in which a woman births her baby is considered to be influenced by her social environment. The position adopted by a woman in labour has not only physiological stimuli but socio-cultural ones as well. Throughout the twentieth century women have been encouraged to remain in bed during labour and for the birth, which can be viewed as a position more convenient for the accoucheur, as this enabled easier access to undertake continuous fetal monitoring, intravenous therapy, vaginal examinations and to administer analgesia. A review of history however suggests today's birth postures were decreed and adopted on the basis of custom and convenience rather than physiological and anatomical indications and scientific data. There has been no study to examine the social context of women's choice of birth position or the influence of birth setting. This study was undertaken to explore what concerns, principles and environmental factors guide women in their choices regarding birth positions. The study used qualitative methods of data collection and employed induction rather than deduction in the analysis. Clarification of these factors may influence the future provision of care by midwives, in addition to highlighting factors which may enhance maternal satisfaction. A grounded theory approach was utilised in this study by means of antenatal and postnatal interviews in two different hospital settings. Several factors that influenced women's choice of birth position were identified, some of which were interrelated. These included physicial and social environment, disciplinary power present in the medical system and related technology. The midwife and her support are also important factors affecting women's choice of birth position. A decision making typology that can be utilised by midwives to enhance their practice and assist women in their choice of birth position had been developed from this study.

This thesis explores the implications of individual caseload practice for midwives. Over the past fifty years childbirth in England has become predominantly hospital oriented, with midwives forced to meet the needs of the institution rather than those of childbearing women. In 1994, a change in government policy for the maternity services attempted to address the dissatisfaction felt by mothers and midwives. The model for caseload midwifery was developed from their recommendations. Midwifery retains an ideology of independent practice yet the reality of working in a subservient position to obstetricians and controlled by the dictates of an institution have been seen in some studies to have undermined midwives' practice. However, their willingness and ability to work in a more independent manner was questioned. This study explored the implementation of caseload midwifery within a highly medicalised inner-city NHS maternity service. Working in partnership, within small groups, each midwife carried a caseload of 40 women per year. No longer based in the conventional hospital or community services, the midwives worked where and when appropriate, to meet the needs of their women. The research was undertaken over 46 months using an ethnographic approach and a variety of data collection methods. The prolonged study period facilitated an understanding of the development of caseload practice from its implementation into an established service. This thesis explores the adaptations the midwives needed to make on moving from conventional practice into caseload practice. Comparison of the difference services offers an understanding of the ways in which organisational features can influence the practice and meaning of midwifery. The control over and uses of time emerged as an important theme in this regard. Of particular note was the high level of job satisfaction expressed by the caseload midwives and their consideration that this model enabled them to practice "real midwifery", phenomena which are explored within the thesis. In working 'with' women, it is argued, the midwives developed a form of authority that had not been facilitated with the conventional services, and which contributed towards a new form of professionalism for the midwives. Although considered by many to be independent and 'isolationist', the strengths of caseload practice were seen to be in the context of group and inter-professional relationships, and the relationships midwives formed with mothers and their families as their work became re-embedded in the society in which childbirth occurred and had its meaning.

The aim of this thesis was to explore storytelling of Icelandic midwives' working lives, in the period from the mid twentieth century to the present time. This ethnographic narrative study was designed with a broad perspective looking at birth stories of midwives as mine full of their knowledge to identify and uncover. Interviews were conducted with twenty midwives to collect birth-stories that represent the social and cultural world of childbirth and midwifery in Iceland, and theory was to arise inductively from the midwives' own telling. Furthermore, one focus group interview with six midwives was conducted and field notes were used to gather more stories. The narrative analysis was designed by means of identifying the plot of the midwives' birth stories, which was identified as being "with woman", leading the focus towards midwives' relationship with women and their inner ways of knowing. The findings suggest that Icelandic midwives have a common philosophy of care that is associated with a midwifery partnership model, incorporated in the ideological statements of the Icelandic midwifery education in Iceland. Yet, in a diverse culture of changing childbirth, the birth stories illustrated the complexity of maintaining balance being pressed to base their work on conflicting models of care, including the social narrative of medical dominance. The research adds information and a deeper understanding of inner knowing of midwives, intuition and spiritual awareness in practice. The "act of being with" or yfirseta "sitting over" at birth was identified as being crucial for preserving and developing this kind of midwifery knowledge integrated with other kinds of knowledge systems. The midwives' storyline demonstrated three different types; one developed by learning from practice experience and the second was of more spiritual nature, even transcendence. The third type referred to the connective knowing where the two types overlap based on a reciprocal relationship with the woman - their connective way of knowing, which needs to be explored further. It is imperative to develop further narrative methodologies in different cultural context, to identify the central concepts of the midwife-with-woman relationship. Furthermore, research is needed on how the relationship affects development of midwifery knowledge, including the intuitive and spiritual, which provides safety of chidbirth.