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.

Developing a safety culture: The unintended consequence of a ‘one size fits all’ policy. Background Adverse events in maternity care are relatively common but often avoidable. Evidence suggests it is necessary to understand the safety culture of an organisation to make improvements to patient safety. The safety domains that are thought to influence safety culture in health care include: Safety Climate; Teamwork; Working Conditions; Perceptions of Management; Job Satisfaction; and Stress Recognition. Little is known about the safety culture in the Australian maternity setting, which was the impetus for this Study. This thesis reports an examination of the safety culture in a maternity service in New South Wales (NSW). Setting The Study took place in one maternity service located in two public hospitals in NSW, Australia. Concurrently, both hospitals were undergoing an organisational restructure. Design This mixed method research study used a concurrent triangulation design and included two Studies. The Policy Study explored the policy context in which the maternity service was situated; and, the Service Study examined the safety culture within the maternity service. Data collection included: • A policy audit and chronological mapping of the key policies influencing safety culture within the maternity service. • Safety culture surveys, the Safety Attitudes Questionnaire and Safety Climate Scale (59/210, 28% response rate) that measured the following six safety culture domains; Safety climate; Teamwork climate; Job Satisfaction; Perceptions of management; Stress recognition and Working conditions (Sexton et al., 2004). • Semi-structured interviews (15) with key maternity, clinical governance and policy stakeholders. Results The safety culture was found to be lacking across all six safety domains. The key finding was that the overarching policy context created unintended consequences for the maternity service and adversely influenced their capacity to have a positive safety culture. These unintended consequences reduced their available infrastructure and capacity to respond to adverse events; and created a lack of leadership at all levels to drive the safety and quality agenda. The safety culture was also influenced by inadequate communication during the escalation of care; inadequate supervision of junior medical staff; difficulty ensuring the right staffing and skill mix, and low staff morale. Conclusion The safety culture in this maternity setting was complex, context-specific but importantly, influenced by the broader policy context in which it was situated. This Study provides evidence that the policy context needs to be included as a seventh safety culture domain in health care. This Study has demonstrated the importance of policy on the capacity to ensure patient safety. Implications The policy context has not been previously identified as being important when addressing the safety culture in health care. Considering the influence of the policy context in relation to safety culture is an important step to develop strategies to improve patient safety in other settings. This is an area for future research.

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 study of women's views of maternity services in the Northern Sydney Area Health Service was conducted as a result of the changing patterns of use of the Area's 7 obstetric hospitals. 340 primiparous women living in the Northern Sydney Area who had given birth in the previous six months were approached in Early Childhood Health Centres and asked to complete a survey exploring the factors influencing their choice of obstetric hospital, postnatal length of stay in hospital, and overall satisfaction with their choice of hospital. Of the 315 eligible women, 312 (99%) consented to participate and 297 (94%) completed the survey. Overall, reputation of the hospital and quality of nursing care were the most frequent reasons given for choice of hospital and there was some evidence that women selected different hospitals for distinct reasons. Women's postnatal length of stay ranged from less than 1 day to 11 days with an average of 5.3 days. Private patients stayed an average of 1 day longer than public patients, after adjusting for delivery type and pregnancy induced hypertension. There was little evidence that women in the Northern Sydney Area Health Service desire a shorter postnatal stay with the majority of women reporting they were satisfied with their length of stay. Overall, women displayed high levels of satisfaction with their choice of hospital; at least 90% of women attending all hospitals except one reported that they would choose the same hospital for the birth of another baby. This study provides valuable information, based on the experiences of the service users, to help guide the Northern Sydney Area Health Service in the provision of its maternity services to ensure they meet the changing needs of women and their families.

Currently in Australia, 80% of women are employed during first pregnancy, and 40% resume employment in the postpartum. The first aim of this study was to identify which of a broad range of factors, including maternal preferences, maternal separation anxiety and maternity entitlements, contributed to maternal employment in the first 10 postpartum. The second aim was to identify the contribution of women’s satisfaction with employment arrangements to their psychological well-being. Participants were 165 employed pregnant women over 18 years of age and with sufficient English for completion of study materials, systematically recruited in the third trimester of pregnancy. Data were collected in pregnancy and at 3 and 10 months postpartum. Maternal preferences, not or no longer breastfeeding and lower maternal separation anxiety were associated with significantly increased likelihood of resuming postpartum employment when maternal age, educational attainment and occupational status were controlled for. A constellation of adverse employment conditions made independent contributions to measurably worse maternal mood including experiencing sexual discrimination in pregnancy, no maternity entitlements when known determinants of poorer maternal well-being were controlled in regression analyses. These findings provide evidence about the relevance of structural determinants to maternal well-being, and highlight the urgency of a national paid parental leave scheme in Australia.

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 (M.P.H.)--University of Michigan, 1946.

Thesis (Ed.D.)--Teachers College, Columbia University, 1974. / Typescript; issued also on microfilm. Sponsor: Alice R. Rines, . Dissertation Committee: Paul Vahanian. Includes bibliographical references (leaves 141-153).

Thesis (M.S.)--University of Michigan, 1998. / Includes bibliographical references.

Thesis (M.P.H.)--University of Michigan, 1946.