Research Doctorate - Doctor of Philosophy (PhD) / The thesis involves a re-examination of feminist views of the childbearing body from a post-structuralist perspective and applies these theoretical ideas to an empirical investigation into contemporary childbirth and midwifery. Critiques of medicalised childbirth developed in Australia, Britain and the USA in the 1970s are related to debates within feminism about appropriate ways to theorise motherhood and the female body as well as to understand the role played by midwives and doctors in childbirth. It is argued these critiques were the product of three strands of feminism that differed in their analysis of gender politics, their philosophy of knowledge and their understanding of power. The three critiques are also related to differences between the USA, Britain and Australia in respect of their medical system, ways in which the history of childbirth practices are viewed and differences between the professional roles of midwives. It is argued that these critiques need to be modified by more recent post-structuralist feminist approaches, particularly the way in which bodies are shaped by language and power is related to the distribution of knowledge The empirical study concentrates on a maternity unit in a regional town in New South Wales. The unit was studied through repeat interviews with mothers attending the hospital for the birth of their second or a later child, interviews with the midwives and doctors working in the unit and observations over several months. Childbirth is re-imagined as a drama and found to be an intense embodied experience shaped in turn by the practices of the hospital and the changing boundaries between medicine and midwifery, relationships of the women with the staff and the women’s own diversity. This approach to the analysis of the interview data demonstrates the limitations of the liberal feminist critique that there is insufficient rational and ‘scientific’ evaluation of childbirth practices, the radical feminist critique that the key issue is men’s domination of women’s bodies and the materialist feminist critique of the lack of fairness and support given to childbearing women, while showing how these discourses continue to circulate in debates over the management of childbirth.

A key midwifery activity is the support of a woman in labour. Pain in labour has been extensively researched from the woman's perspective, but less has been explored in relation to the midwife and her approach to pain. The way in which the midwife works with a woman and her pain in labour is the focus of this qualitative study, using Heideggerian hermeneutic phenomenology. This philosophical approach seeks to uncover or illuminate aspects of the midwife's practice which are frequently taken for granted in their everydayness. Seven midwives, including both independent practitioners and hospital-employed, were interviewed. Their narratives were analysed to uncover the meaning of the way in which midwives work with women and their pain in labour. The findings of this thesis suggest that midwives work by interpreting the woman's pain. Before the pain begins, they 'leap ahead' to help them anticipate the pain and how they will confront it. During labour, midwives give pain meaning by translating its purpose in that context. They 'leap in' when required, sometimes using 'self as an intervention. Midwives interpret women's pain through their understanding of lived time. They know how the perception of time passing changes depending on the setting for labour or the amount of anxiety and pain the woman is experiencing. Midwives use time in their work. They break it down to help a woman focus on a single contraction rather than looking too far ahead toward the unknown. Time can be a midwife's friend when the arrival of the baby replaces the urgent need for pain relief. It can also be her enemy if her interpretation of a woman's pain differs from the woman's perception. The memory of pain may persist for the woman, after labour has finished, with a backlash for the midwife. Some midwives believe in the process of birth and the woman's ability to labour with such conviction that they gain a woman's complete trust. At her most vulnerable time, they encourage the woman to call upon inner reserves and be truly empowered by her experience.

This research explored the ethical nature of the mother-midwife relationship in order to refine our understanding of the place of ethics in the context of everyday midwifery practice – the practice of ‘being with woman’ in childbirth. The ethics explicitly available to midwives are derived from practices such as moral philosophy and bioethics, whose ethical frameworks are reductionist in their exclusion of context and relationship. Given that the midwifery profession is currently promoting a model of practice built on partnership and relationship, existing codes and frameworks are examined for their adequacy. An assumption of the study was that a distinctive midwifery ethic was implicitly available in the lived realities and shared engagement of mothers and midwives, embedded in practice. Conceptual theoretical research methodology facilitated exploration of the taken-for-granted assumptions of established theory, official policies such as Codes, and the profession’s literature. Feminist-constructivist theory formed the epistemological basis for gaining insight into the implicit ethics of midwifery. Personal narratives of mothers and midwives were analysed and interpreted for meaning, and transcripts returned to participants for validation. These constructed meanings were then compared and contrasted with those explicit in Codes and current literature. The central theme to emerge from the narratives was the use and abuse of power in relationships. Other major themes were institutional dominance consistently used to describe the status quo, values conflict especially linked to workplace/service provider versus personal/professional midwifery ethics, and the ethical adequacy of a ‘being with woman’ relationship. Findings indicate that midwifery does need a different ethic to that of bioethics and problem-solving principlism, and that such a new ethic would look like those promoted by feminist-virtue ethics. The latter not only redress the politics of the existing hegemonic maternity services system, but they also place women’s concerns central to practice and deliberation. The aspirations, values and lived reality of mothers and midwives, and the commitment of the professional-friend midwife to the particularity of the birthing woman, are the focus of a reconstructed ethic for midwifery practice, an ethic which reunites morality and personal interest. Implications and recommendations are discussed.

Thesis (Ph. D.)--University of Technology, Sydney, 2005. / Includes bibliographical references (p. 301-316).

Thesis supervisor: Susan C. Lawrence. Thesis supervisor: John Raeburn. Includes bibliographical references (p. 339-354).

Thesis (Ph. D.)--University of Oregon, 2005. / Typescript. Includes vita and abstract. Includes bibliographical references (leaves 339-377). Also available for download via the World Wide Web; free to University of Oregon users.

A quantitative, descriptive non-experimental design was used to identify the factors that influence clinical teaching of midwifery students in selected postnatal clinical settings in Tanzania. Structured questionnaires were used to collect data from midwifery tutors/preceptors. The major findings of the study showed that both the professional and educational qualification of tutors was low; tutors and preceptors were overworked due to shortage of staff; the school skills laboratory and postnatal wards lacked equipment and necessary supplies; there were no clinical accompaniment guidelines, and overcrowding of postnatal patients. Recommendations included developing the clinical teaching guidelines, employing more tutors, preceptors and clinical staff; improving the tutors'/ preceptors' educational and professional qualifications and updating the qualifications of ward supervisors and clinical facilitators. / Health Studies / M.A. (Health Studies)

This thesis explores the newly established role of midwife practitioner (MP) and its impact on midwives and obstetricians in a maternity unit in Wales. MPs manage the care of women at high obstetric risk and carry out aspects of care, such as assessment, diagnosis and the development of management plans, which in the past were predominantly performed by obstetricians. This qualitative study employs a focused ethnographic approach and uses a purposive sample. Phase one consisted of seven focus groups, which were held between May and August 2004, with midwives (n=48) from maternity units in Mid and South Wales. In Phase two, participant observation was undertaken with MPs (n=3) over a two-week period encompassing eight 12-hour night shifts, during November and December 2004. For Phase three, semi-structured interviews were conducted with midwives (n=10), clients (n=10) and obstetricians (n=7), between July and December 2005. Phases two and three were carried out in a maternity unit in South Wales. The key findings of this study demonstrate that the lack of planning for the MP role inadvertently resulted in the creation of a distinct health care role, which encompasses positive aspects of both midwives' and obstetricians' work to provide safe and acceptable care for clients. The MPs in this study are committed to providing holistic care that takes into consideration the emotional and social needs of women and their families. In addition, these MPs are developing confidence and analytical skills, normally demonstrated by medical staff. However, further initiatives such as allowing MPs to prescribe, or to refer to other specialties, have not yet been adapted to support these new roles. It is too early to see the full impact of this role, but it is argued that it will have no significant effect on the work of the other midwives. MPs, however, do have the potential to impact upon the work of the obstetricians. This study contributes to the current body of knowledge concerning policy and practice for maternity care by examining a new role early in its genesis. This study makes a number of recommendations, including extending the number of MPs employed in Wales, the need for careful planning of future extensions to the midwives' role and further research into the safety and effectiveness of the MP role.

Substantial benefits can be gained by participating in regular physical exercise, however only a minority of women meet current pregnancy exercise recommendations and there is limited understanding of women’s decision-making regarding exercise in pregnancy. The purpose of this constructivist grounded theory study was to develop a theoretical insight into the factors that influence women’s decisions regarding exercise in pregnancy and how they process the influences and multiple alternatives they encounter. The constructivist approach drew on the subjective researcher/participant interrelationship to co-construct meaning from the data and ultimately render the women’s experiences into theoretical interpretations. The theory presented was built inductively from the experiences of 10 pregnant women who exercised regularly, supplemented by insights from theoretical sampling of fitness experts, internet forums and extant literature. Longitudinal, audio-recorded semi-structured interviews occurred twice during each pregnancy and 6-8 weeks postnatal. Data generation and data analysis ran concurrently and iteratively using the constant comparative method of analysis. Theoretical constructs generated by the data were progressively amplified and clarified through a series of inductive-deductive cycles and theoretical sampling that drove the evolving interview schedules. Theorising ideas in the form of detailed memos was a fundamental part of the analysis and enabled a detailed audit trail to be established. The resultant substantive theory of ‘Accommodating the pregnant self’ conceptualises pregnancy as a transitional period during which women’s self-identity is modified. ‘The exercising self’ was a salient and valued facet of the women’s self-identity and continuing to exercise enabled women to maintain a degree of continuity and control that was integral to their sense of maintaining and to a degree regaining their past valued self. Decisions regarding exercise were influenced by a complex interplay of contextual factors that simultaneously encouraged exercise and rest. This consequently triggered a degree of identity conflict between two domains of their self-identity, ‘the exercising self’ and ‘the pregnant self’. The women reacted to the challenges to their identity through the process of self-identity regulation. Through this process they gradually re-constructed their self-identity to accommodate their pregnant self while contemplating possible future selves against various self and social normative standards. Negotiating conflicting identities was an integral component of the decision-making process, and ultimately resulted in many of the women modifying their activities to accommodate the pressures they faced to conform to social ideologies of ‘the pregnant self’. The theory explores a range of strategies that the women used to deal with identity conflict, particularly drawing on selective perception and self-justification to resolve cognitive dissonance. It also highlights a duality in the factors that influenced their decisions which suggests women’s identity characteristics resulted in a propensity for behaviour to be steered by either internal (personal) or external (relational and environmental) influences. The substantive theory underscores the significance of self-identity in steering the decisionmaking process. The findings provide insight into how women might be better supported to make informed and assured decisions regarding lifestyle choices. The theoretical potential to inform interventions to enhance activity levels in a wider population is highlighted.

Previously documented evidence suggests that motherhood is potentially an important time for change in drug-using behaviour. My research interest for this longitudinal phenomenological study stemmed from practice observations where methadone-treated women struggled to prove their trustworthiness as mothers. They consistently reported frustration in the face of continued professional suspicion of their identity as drugusers. The essence of the phenomenon is therefore described as an existential tension experienced by breastfeeding mothers in methadone maintenance treatment during the first 12 weeks of motherhood. The aim of this thesis is to reveal the previously hidden inter-subjective and social realms of their lived worlds.