Elizabeth Newnham

Midwifery Directions: The Australian Maternity Services Review

Abstract Australian midwifery is at a crossroads, and the 2009 Maternity Services Review and subsequent Report by the Australian federal government have revealed significant issues that were previously obscured. This article outlines the current position of Australian midwifery by examining the recently published Commonwealth Report of the Maternity Services Review, as well as looking at some South Australian Department of Health birth-related policies. The Report recommends important and positive changes for midwifery, but with caveats that may lead to greater restrictions on midwifery practice. The policies, while endorsing possible alternatives for women, also illustrate how birth options are ‘problematised’. Relationships between government, medicine and midwifery are explored throughout the article, illuminating the tension for midwives between aligning with professional and scientific discourses, and those that are woman-centred. Free-standing birth-centres are presented as a possible way forward in order to ease the present dichotomy between ‘scientific’ and ‘experiential’ birthing care.

Birth control: Power/knowledge in the politics of birth

Abstract Choice and control for birthing women have recently come under the global spotlight as a human rights issue, and are likely to remain so while midwives are being targetted for providing home birth care. While focussing on these issues appears to further widen the dichotomy between medicine and midwifery, understanding how this divide is maintained is necessary if we are to move beyond it. This article, utilising Foucault’s theory of genealogy, recapitulates how midwifery knowledge came to be subjugated by a dominant medical discourse, particularly through the process of hospitalising birth. The submission of the Australian Medical Association to a government enquiry into maternity services is then examined to illustrate how discourse is perpetuated, and how medicine still configures itself as the dominant birth discourse in Australia. The importance of focussing on midwifery specific knowledge, using the notion of embodiment, is put forward.

Access or Egress? Questioning the "Ethics" of Ethics Committee Review for an Ethnographic Doctoral Research Study in a Childbirth Setting

In this article, we discuss the principal difficulties in gaining ethics approval for an ethnographic midwifery doctoral research project in a hospital setting in South Australia. The research focus is on the various personal, social, institutional and cultural influences on women making a choice about whether or not to use epidural analgesia in labour. The obstacles encountered in gaining human research ethics committee (HREC) approval are discussed within the wider context of the benefits of ethnography as a research methodology, as well as the potential consequences to ethnography when assessed by quantitative research standards. By sharing our experience, we add to the current literature debating the “ethics” of ethics committee review in qualitative research approval. Engaging with the academic debate surrounding “ethics creep” – the increasing jurisdiction of ethics committees over research design – we consider the possibility of moving beyond principle-based ethics towards an ethical theory that more fully addresses the complexities of ethnographic research.

Paradox of the institution: findings from a hospital labour ward ethnography

BackgroundInterest in the influence of culture on birth practices is on the rise, and with it comes a sense of urgency to implement practices that aid the normalisation and humanisation of birth. This groundswell is occurring despite a broader cultural milieu of escalating technology-use and medicalisation of birth across the globe. Against this background, rates of epidural analgesia use by women in labour are increasing, despite the risk of side effects. Socio-cultural norms and beliefs are likely to influence pain relief choices but there is currently scant research on this topic.MethodsThis study was undertaken to gain insight into the personal, social, cultural and institutional influences on women in deciding whether or not to use epidural analgesia in labour. The study had an ethnographic approach within a theoretical framework of Critical Medical Anthropology (CMA), Foucauldian and feminist theory. Given the nature of ethnographic research, it was assumed that using the subject of epidural analgesia to gain insight into Western birth practices could illuminate broader cultural ideals and that the epidural itself may not remain the focus of the research.ResultsFindings from the study showed how institutional surveillance, symbolised by the Journey Board led to an institutional momentum that in its attempt to keep women safe actually introduced new areas of risk, a situation which we named the Paradox of the institution.ConclusionsThese findings, showing a risk/safety paradox at the centre of institutionalised birth, add a qualitative dimension to the growing number of quantitative studies asserting that acute medical settings can be detrimental to normal birth practices and outcomes.

‘It's your body, but…’ Mixed messages in childbirth education: Findings from a hospital ethnography

OBJECTIVE to investigate the personal, social, cultural and institutional influences on women making decisions about using epidural analgesia in labour. In this article we discuss the findings that describe practices around the gaining of consent for an epidural in labour, which we juxtapose with similar processes relating to use of water for labour and/or birth. DESIGN ethnography. SETTING tertiary hospital in Australian city. PARTICIPANTS sequential interviews were conducted with 16 women; hospital staff (primarily midwives and doctors) participated during six months of participatory observation fieldwork. FINDINGS women were not given full disclosure of either practice and midwives tailored the information they gave according to the institutional policies rather than evidence. KEY CONCLUSIONS informed consent is an oft-cited human right in health care, yet in maternity care the micro-politics of how informed consent is gained is difficult to ascertain, leading to a situation whereby the concept of informed consent is more robust than the reality of practice; an illusion of informed consent exists, yet information is often biased towards medicalised birth practices. IMPLICATIONS FOR PRACTICE as primary maternity care-givers, midwives have a role in providing unbiased information to women; however it appears that hospital culture and policy affect the way that this information is presented. It is arguable whether women in such instances are giving true informed consent, and for this reason, the ethics of these hidden practices are questioned.

Critical Medical Anthropology in Midwifery Research: A Framework for Ethnographic Analysis

In this article, we discuss the use of critical medical anthropology (CMA) as a theoretical framework for research in the maternity care setting. With reference to the doctoral research of the first author, we argue for the relevance of using CMA for research into the maternity care setting, particularly as it relates to midwifery. We then give an overview of an existing analytic model within CMA that we adapted for looking specifically at childbirth practices and which was then used in both analyzing the data and structuring the thesis. There is often no clear guide to the analysis or writing up of data in ethnographic research; we therefore offer this Critical analytic model of childbirth practices for other researchers conducting ethnographic research into childbirth or maternity care.

Institutional Culture: Discipline and Resistance

This chapter presents the setting both physically and culturally. We take a critical position on the role of the institution, drawing on the theory of critical medical anthropology (CMA) and Foucault’s conceptions of panoptic surveillance and the medical gaze. Using the field note data and centring on two disparate notions—organisational and midwifery technologies—institutional influence on time, organisation of labour and birth, risk and safety, and midwifery practice are discussed. An inherent contradiction within the institution is revealed.

The Epidural in Context

This chapter presents a historical introduction to birth analgesia and the influence of scientific and medical discourse on understandings of women’s bodies, influencing the ways in which women themselves can frame their own corporeal knowledge. Here, the process of birth, and how it is understood within Western cultural discourses, is investigated more thoroughly. We highlight the influence of biomedicine as a dominant birth discourse and explore current medical knowledge about epidural analgesia, exposing some of the assumptions behind evidence-based medicine and technology use.

Towards the Humanisation of Birth

This book examines the future of birthing practices, particularly by focusing on epidural analgesia in childbirth. It describes historical and cultural trajectories that have shaped the way in which birth is understood in Western, developed nations. In setting out the nature of epidural history, knowledge and practice, the book delves into related birth practices within the hospital setting. By critically examining these practices, which are embedded in a scientific discourse that rationalises and relies upon technology use, the authors argue that epidural analgesia has been positioned as a safe technology in contemporary maternity culture, despite it carrying particular risks. In examining alternative research the book proposes that increasing epidural rates are not only due to greater pain relief requirements or access but are influenced by technocratic values and a fragmented maternity system. The authors outline the way in which this epidural discourse influences how information is presented to women and how this affects their choices around the use of pain relief in labour.

The Politics of Birth

In this chapter, we outline the theoretical perspectives which underpin the book. We primarily use a Critical Medical Anthropology (CMA) approach, which provides a critical focus on the far-reaching influence of medical culture. The CMA lens proffers a useful perspective on the role of technology within the neoliberal milieu of Western capitalism. We also recognise the subtle techniques of power as documented by Foucault, and use a number of Foucauldian methodological devices. The impact of scientific culture on the knowledge and history of women’s bodies is described utilising feminist perspectives.