Midwifery Practice During Birth: rites of passage and rites of protection

Finally I have completed my Phd! It took me six years – the last two mostly writing… and writing… and rewriting. Entire chapters did not make the final ‘cut’. There is so much more I wanted to say (and did) about authoritative knowledge and the ritual nature of midwifery practice. Hopefully I will share this work another way in the future.

My aim was to contribute to an understanding of birth, and midwifery practice, grounded in women’s experience. I believe we need to develop (reclaim?) our own birth knowledge in order to shift the current medical paradigm that is failing women.

The Phd journey has been a rite of passage itself, and I pushed myself to my edge and beyond. I thought about giving up at times, and felt self-doubt about my ability (I left high school with no qualifications and a baby in my belly). I accepted my fears and kept going one step at a time. In the process, I learned not only about my topic, research, and writing; but also about myself.

The abstract is posted below, and you can download the full thesis here. I’d welcome comments, questions and discussion about the research.

Big THANKS to the participants – mothers and midwives – who generously shared their birth stories.

Abstract

This study explored midwifery practice during birth. In particular, the experiences, actions and interactions between midwives and women during uncomplicated, normal births.

Most of the existing literature focuses on outcomes associated with individual practices; and there is a lack of research evidence supporting many of the common midwifery practices carried out during birth. There is also limited research exploring midwives’ experiences and perceptions of their practice during birth; although it seems that the context of midwifery practice, and cultural norms influence practice. Studies exploring women’s experience of birth have identified an altered state of consciousness, and issues of control as key factors. However, there has been very little research specifically examining women’s experience of midwifery practice during birth. This study sought to explore the experience of midwifery practice from both the perspective of the midwife and the woman.

The study is a narrative inquiry, and a feminist approach was taken throughout the research process. Birth stories were gathered from mothers and midwives during in-depth interviews. The participants had either experienced or attended an uncomplicated vaginal birth, and were encouraged to share their story of this experience. Narratives were created from the interview transcripts and analysed to identify common themes. An explanatory framework ‘rites of passage’ was then applied to further illuminate the narrative of midwifery practice during birth.

The findings are presented in three chapters. The first focuses on the mothers’ experiences of birth as a rite of passage. This chapter provides the foundation for the following chapters that present midwifery practice during birth. Midwives enacted ‘rites of passage’ during birth that tended the boundaries of aloneness, and nurtured self-trust and inner wisdom. Midwives also enacted ‘rites of protection’ which contradicted rites of passage, but tended the needs of the institution. Tensions arose between these two types of rites, and conflicting cultural values were transmitted and reflected through their performance.

Findings are discussed in relation to the literature, and the thesis concludes with recommendations for midwifery practice, midwifery education, and further research. Recommendations centre on a model of midwifery practice as ‘ritual companionship’ as the basis for developing midwifery practices that are aligned with women’s experience of birth.

Conceptual map of findings

About midwifethinking

independent midwife, lecturer and student of all things birthy
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57 Responses to Midwifery Practice During Birth: rites of passage and rites of protection

  1. Danielle says:

    Congratulations!!! This spring I finished my master’s degree in a very similar position: coming out with no specific professional qualifications, having had a daughter, and pushed myself to the brink of sanity. My thesis also focused on the rite of passage aspects of midwifery care, but within the state of Alaska. I look forward to reading your work and would be happy to share mine as well if you have time/interest.

  2. Wonderful!!! and hoorah!! this is the info we need:
    “…to develop (reclaim?) our own birth knowledge in order to shift the current medical paradigm that is failing women….authoritative knowledge and the ritual nature of midwifery practice.”
    Bring it on Dr Reed!
    At Your Service,
    Jane Hardwicke Collings
    xxxx

  3. Alison Walker says:

    love your work Rachel xxx

  4. amelia o connor says:

    Congratulations and a massif well done to you on all your hard work and commitment to your goal – inspiring !

  5. Holly Platt Wells says:

    Congratulations! I look forward to reading it. It might take me a while.

  6. Claire says:

    Fab Fab Fab!! I shall be taking some time out to fully absorb your thesis. Congratulations on finishing, it really is a hard hard slog!

  7. Denise Hynd says:

    Dear RACHEL, So many midwives and women are encouraged by your blog and now this monumentous work and sharing – we all thank you as well as congratulate you!!

  8. Denise Hynd says:

    PS we must toast you in Sydney next month!!

  9. Liz Newnham says:

    Well done, Rachel. It sounds great and I look forward to having a read. I’m in the process of writing mine, so naturally I am awe-inspired by your completion! :) Thanks for sharing

  10. Carolyn McIntosh says:

    Your conceptual map is beautiful, a splendid example of simplicity which illustrated concepts not always easy to explain. .I look forward to reading your work.

  11. Milana Silva says:

    Many many congrats!!
    I’m sure it is a wonderful paper that will be able to make a great impact in midwifery practice!!, can’t wait to read it! Actually I’m gone to dive in it just now!

  12. Pam Yenawine says:

    Congratulations! Have you ever heard of APPPAH (Association for Pre and Perinatal Psychology and Health. Your research would be welcome at the annual conference!!! This year’s conference is in November – near Monterey CA. Check it out at http://www.birthpsychology.com. You will find a large group of like-minded folks!!!

  13. Robyn says:

    Wow and congratulations. Just spent morning reading your thesis, the housework can wait :). Thankyou for sharing it and making it accessible. I agree with everything I could understand which was most of it, just not some of the researchy things. Doulas are definitely filling the void left by midwives who need to meet the needs of the institution. It could be argued doulas are the new midwives and midwives the new obstetric nurses. I do hope the tide is turning and that this thesis contributes to a surge of more research in these areas.
    The environment is so important and I love your suggestion of simulating good environments for physiological birth rather than just simulating obstetric emergencies.
    I went to a OneJustWorld talk the other week and a Doctor from Sudan was talking about maternity care needing to be culturally acceptable and that sending labour beds to Sudan wasnt the answer to the countries high maternal mortality rate because women wouldn’t use them. It made me wonder what would happen if labour beds were removed from labour rooms here. A quick google search found this has already been studied http://www.eurekalert.org/pub_releases/2009-07/uot-lwt070609.php
    Your thesis definitely gives people a lot to think about!

    • Hi Robyn
      Thanks for your feedback re. my thesis. And I know a few places have attempted to or have implemented ‘bed-free’ birth spaces. Even in a standard hospital birth room it is possible to re-create a more ‘nesty’ environment. I used to push the bed to the side (closest the door – so anyone coming in was blocked by the bed), put a soft ‘mattress’ on the floor in the corner of the room furthest from the door, with a bean bag to lean on. And encourage the woman to nest there or in the shower/toilet. My biggest bug bear is leaving birth room doors open with just a curtain drawn across.

      • Robyn says:

        Love it!

        • Jill says:

          Hi Robyn and Rachel,
          This was the focus of a project I designed and implemented in DPRKorea (North Korea) in 2004-2005. The women were birthing on very uncomfortable labour ‘beds’ (generally just a wooden platform or 1/2 bed raised to support women in a semi-sitting position, with feet elevated), sometimes facing a window without curtains. The rooms were also very cold in sub-zero winter months. As well as teaching the midwifery, nursing and medical staff about normal physiology of labour and how to support it, we made changes to birth rooms which included removing the ‘bed’ (in places where that wasn’t possible, it was put to the edge of the room and served as shelving for the most part), furnishing the rooms with mattress on the floor, cushions, pillows, stools and chairs (no bean bags available), curtains for windows and heating. The rooms were also re-tiled to help give a more inviting atmosphere (I would have preferred another option for floors, but tiles were the most practical available to us).

          When we undertook monitoring and evaluation field trips, the staff were very enthusiastic about the changes and really excited that the babies were being born more quickly and apparently much more easily when the women had the freedom to move about and change positions. In fact, so enthusiastic that they would greet me at my car when I arrived at health facilities and start telling their stories of successful births in a very animated manner, so I knew that it wasn’t just ‘going along with it’ out of politeness, and then doing their own thing when I wasn’t around…

          So, it’s very possible to make such small changes that make a real difference in many different places. Unfortunately though many donors, organisations and agencies think they are doing good by donating the latest in technology (including whizz-bang labour beds) to treat complicated labour instead of supporting normal physiology to prevent complications in labour.

          • Thanks for sharing your experiences. Yes, I think a big difference can be made without spending big money on whizz-bang equipment. While I was in Nauru the hospital was given a CTG machine (which the staff did not know how to interpret) and a complicated incubator. The midwives were already doing a great job using skin-to-skin kangaroo care for prem babies.

  14. I’ve followed your blog for a few months and I’m so happy to hear that you have completed the PhD.

    I’m starting school this September for my Masters in Midwifery and as a male in a woman’s world … I am scared that I’ll be an outcast.

    Looking forward to reading your thesis!!!

    • Hi Michael
      I am sure you will not be an outcast! I wrote my BSc(Hons) dissertation on ‘Male Midwives: power and gendered practice’. You can download it if you are interested… although it is very out of date now. (2001):https://dl.dropboxusercontent.com/u/19684636/Publications/2001_BScHons%20dissertation.pdf
      I think all midwives need to be aware of the power dynamics of the mother-midwife relationship. The sex of the midwife is just one factor. If you make it to the 3rd chapter you will see that my argument is that the ‘gender’ of care is more important that the sex or gender of the midwife. There are plenty of female midwives who do not provide woman-centred care and plenty of male midwives who do.
      I have worked with some amazing male midwives. Good luck with your education and practice :)

  15. Tara says:

    Congratulations! I’ve just had our third child & can’t begin to thank all my midwives, I think you do an incredible job and the good ones are priceless.

  16. Catina Adams says:

    Congratulations, that is an awesome achievement. With best wishes, Catina Adams

    ________________________________

  17. Denise Hynd says:

    As you say “For mothers, the cultivation of self-trust began in pregnancy, and midwives then
    reinforced self-trust during labour.” I suspect the reverse is true for women who have complicated/interventinist births, though the social climate of fear and danger around childbirth means distrust starts so much earlier and it so easy to be saturated by it when you are pregnant!
    Thank you for a re-affirming and well written (relatively easily understood) academic effort!

  18. ckb says:

    congrats on the mammoth effort of completion but also again putting the essence of midwifery out there , how important it is for our future that attachment is able to occur

  19. Congratulations. I enjoyed reading your thesis, and your blog is always well written, researched and informative. The topics you choose to write about have wide appeal. Great work, the PhD is a journey as much as an outcome.

  20. Thanks for your comments and feedback. It is much appreciated :)

  21. Pingback: Midwifery Practice During Birth: rites of passage and rites of protection | Staywellfireyourdoctor's Blog

  22. staywellfireyourdoctor says:

    Reblogged this on Staywellfireyourdoctor's Blog and commented:
    reblogging this

  23. Huge congratulations! I share your posts with my couples (I’m a doula and hypnobirthing teacher) often and can’t wait to read this and be inspired all over again!

  24. janice bass says:

    Many congratulations Rachel on achieving your PhD sounds like it was quite a transformative journey just like giving birth. Thank you for such a wonderful contribution to birth wisdom and midwifery knowledge ~ I look forward to reading your thesis and appreciate your generous and informed sharing ~ with much respect and gratitude :)

  25. I have been unable to access a successful download pdf of your thesis. Can you send it to me directly perhaps?

  26. Ginnie says:

    Congrats to you!

  27. Patricia says:

    This is very interesting,thank you for posting and I will look at the thesis as well. There seems to be a lot more awareness of the issues you raise in the media at the moment, eg http://huff.to/19o4Ko1

  28. Mum says:

    Any more posts? This blog is very informative and I’d love to read more.
    Perhaps a post on what to look out for when home birthing that should require a transfer to hospital (or a reply to this comment)?
    I have learnt many ways to avoid hospital which hospitals normally call a induction or CS for but I wouldn’t know if I was in danger at home although I guess a midiwfe would but I’d be glad to read about it.

    • Essentially if pregnancy/birth becomes pathological rather than physiological and/or if a complication arises during labour. A midwife should be monitoring for this and tell you if you are in danger. There are many reasons for a transfer to hospital… or starting labour in hospital. I’d be reluctant to write a post about it in case it people took it as ‘advice’ – each individual woman is responsible for her own decisions around birth. If a midwife attends the birth, she is responsible for sharing information, identifying problems and dealing with complications if they arise. Essentially any concerns about the mother or baby’s wellbeing are an indication for transfer eg. pre-eclampsia, fetal distress, bleeding…

  29. Mum says:

    Me again :) Any posts on ‘risky positions’ like breech babies? I’ve seen the OP post but any others coming please?

  30. Mum says:

    I can’t seem to keep away. I wonder if it’s better for me to email you or carry on posting on here. :)

    I seem to have pain in the ischium bone, one sided. It’s mainly when I walk and what puts me off walking. Not excruciating but it makes me walk slowly.

    It could be pelvic girdle pain, or SPD at most? I have been told to be referred to physio by GP (in the UK) but I don’t want anyone looking or touching me down there (why after thinking I want a home birth where no one looks lol). Is this a unavoidable situation? And thank you a million for reading and answering.

    • I’m not sure what your pain is from. The physio should be able to work it out. As for vaginal examinations… it doesn’t matter where you birth no one can exam you without your consent. If you don’t want any examinations you shouldn’t get any.

  31. Jenna Simons says:

    I am only about a third of the way through your thesis and I’m SO excited about it. I think I need to start a Midwife Coffee Hour in my city so I can have colleagues to discuss and engage with (and share our anecdotal stories undervalued by the mainstream scientific community). At any rate, I have come into studying to become a CPM after a long debate with myself: I thought I was too radical to be a midwife. I thought that my skepticism of charts, graphs and “scientific” observations of birth would keep me out of a profession that seems to be becoming increasingly medicalized in spite of all the evidence for the contrary. I have often asked myself how to talk about some of the problems I see in birth research; the obvious holes in the methodology, the unchallenged assumptions and the dismissal of anecdotal evidence…even when the anecdotal evidence was confirmed by hundreds of homebirth midwives (the ONLY people in the United States who have even seen actual undisturbed, natural birth). How could I challenge decades of “experts”…or the very notion of “experts” on birth? Reading my textbooks, I feel so much is wrong in the language, assumptions and methodology.but who am I to challenge it at this stage of my education? Thankfully, you have taken on this momentous task for me! I am in awe at the size of the project and the scope of your courage. (And I can’t wait to read the study you referenced about the “flexible vs. prescriptive” midwives….so much food for thought here; a veritable feast!) Thanks so much for sharing it here!

    • Thanks Jenna (and others)
      Doing PhD can be a very lonely journey and writing the thesis was probably the hardest thing I’ve ever done (I thought about walking away more than once). Knowing it has made an impact beyond my own ‘world’ makes it worthwhile… and if I can inspire other midwives to carry out research and expand midwifery knowledge I would be very happy. A Midwifery Coffee Hour is a great idea! We have a Midwifery Group Meeting (although also open to non-midwives) at the uni once a month. Lots of tea, cake and sharing of knowledge and stories and laughter. A diverse group: students, independent mws, public hospital mws, private hospital mws, doulas = lots of learning.

  32. I am sitting at a snack bar at my university (University of Cincinnati, USA) browsing the internet and I had the idea to take a visit to your blog while eating my salad. As I come to the end of a grueling BA in Anthropology this year and consider my final project and next steps as a birthworker, I was delighted to find that not only do you write awesome posts on midwifery, you are an academic too. This was the confirmation I NEEDED today, to finish this phase even in the midst of a new family dynamic (a new lover/partner and her two girls) a kid with a mysterious bone infection AND a broken foot, and a mom with a serious chronic and terminal immune disorder…and that’s just what is going on right now. I am grateful that I have made it this far.

    I love the connection to authoritative knowledge I see here, along with the Van Gennep model of initiation. Yes! You might be interested in the work of my friend and collegue, Amy Chavez. She just completed a MA on the collateral trauma and unresolved emotional issues that happen for birth workers in our current climate and how we must look to our own psychoemotional health to practice in healthcare as truly with-women, rather than triggered or projecting our feelings outward. She employs the work of Peter Levine and others in neurobiophysiology who work with the somaticization of trauma, and she also employs the 3 step process of birth as initiation.

    As for myself – I came to my BA when my own birth work shifted abruptly into protection against the powers-that-be. I had the insight to step back to occasional doula work and a prenatal bodywork practice, but I miss my vocation so, and I am deeply saddened by a local and global birth climate that encourages lateral violence, dysfunction and distrust. I look forward to a time in my life when my family needs me a bit less, and when I am able to contribute to the body of knowledge on birthing culture(s), racial and class inequality, feminist push-back against the mainstream system, spheres of care that intersect but do not often overlap, and how our physiology and our stories are intimately intertwined for motherbaby and witnesses through this highly enculturated, inherently embodied act. Thank you for the inspiration and the dedication you provide, I look forward to reading the full dissertation, and may include your work in my final readings for this degree, if you don’t mind.

    Lauren

    PS: I began this BA with a 5th grade formal education, as a former unschooler. I had only a trade license as a massage therapist, which I’ve used to support my family as single mama of a now 11 year old daughter. :)

    • Thank you Lauren :)
      We really do need to build and sustain birth knowledge that has women at the centre. One of the barriers to this is that women are often entwined in the challenges of mothering and relationships. I’d be interested in what you do for your final project… I am a little jealous as I always wanted to study Anthropology. I’d also love to know more about Amy Chavez’s work. It is accessible online anywhere?

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