‘Practising outside of the box, whilst within the system’: A feminist narrative inquiry of NHS midwives supporting and facilitating women’s alternative physiological birthing choices.

Abstract

This thesis presents the findings of an original study that explored NHS midwives practice of facilitating women’s alternative physiological birthing choices - defined in this study as ‘birth choices that go outside of local/national maternity guidelines or when women decline recommended treatment of care, in the pursuit of a physiological birth’. The premise for this research relates to dominant sociocultural-political discourses of medicalisation, technocratic, risk-averse and institutionalisation that has shaped childbirth practices in the UK. For midwives working in the NHS, sociocultural-political and institutional constraints can negatively impact their ability to provide care to women making alternative birth choices. A meta-ethnography was carried out, highlighting a paucity of literature in this area. Therefore, the aim of this study was to generate practice-based knowledge to answer the broad research question: ‘what are the processes, experiences, and sociocultural-political influences upon NHS midwives’ who self-define as facilitative of women’s alternative birthing choices’. Underpinned by a feminist pragmatist theoretical framework, a narrative methodology was used to conduct this study. Professional stories of practice were collected via self-written narratives and interviews to understand the processes of facilitation (the what, how, why), their experiences of carrying out facilitative actions (subjective sense-making), and what sociocultural-political factors influenced their practice. Through purposive and snowball sampling, a diverse sample of 45 NHS midwives from across the UK was recruited. A sequential, pluralistic narrative approach to data analysis was carried out, and a theoretical model was developed using the whole dataset. The findings were subjected to three levels of analysis. First, ‘Narratives of Doing’ highlight how and what midwives did to facilitate women’s alternative choices. The sub-themes reflect the temporal nature of a wide range of actions/activities involved when caring for women making alternative birthing decisions. The second analysis; ‘Narratives of Experience’ - highlighted the midwives polarised experiences captured as ‘stories of distress’, ‘stories of transition,’ and ‘stories of fulfilment’. For the third level of analysis, a theoretical model of ‘stigmatised to normalised practice’ was developed using notions of stigma/normal, deviance/positive deviance. A six-domain model was developed that accounted for the midwives sociocultural-political working contexts; micro, meso, and macro. The implications of this research related to a number of identified constraints, protective factors, and enabling factors for midwifery practice. Key barriers included negative organisational cultures that restricted both midwives’ and women’s autonomy. Disparities between the midwives’ philosophy and their workplace culture were highlighted as a key stressor and barrier to delivering woman-centred care. Protective factors related to the benefits of working in supportive, like-minded teams that mitigated against their wider stressful working environments. Facilitating factors included positive organisational cultures characterised by strong leadership where midwives were trusted and women’s autonomy was supported. Therefore, this study has captured what has been achieved, and what can be achieved within NHS institutional settings. Through the identification of both challenges and facilitators, the findings can be used to provide maternity professionals and services with insights of how they too can facilitate women’s alternative birthing choices