The Ethical Nature Of The Mother-Midwife Relationship: A Feminist Perspective A dissertation submitted to The Department of Nursing Faculty of Sciences The University of Southern Queensland For the degree of Doctor of Philosophy By Faye E. Thompson MNSt (LaTrobe), BA (UQ), DipAppSc (NrEd) (QUT), RN, EM. March, 2001
i ABSTRACT 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-forgranted 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
ii 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.
iii CERTIFICATION OF DISSERTATION I certify that the ideas, conduct of interviews, findings, analyses and conclusions reported in this dissertation are entirely my own effort, except where otherwise acknowledged. I also certify that the work is original and has not been previously submitted in whole or in part for any other award at this or any other university. Signature of Candidate Date Faye Elizabeth Thompson ENDORSEMENT Signature of Principal Supervisor Associate Professor Don Gorman Date
iv ACKNOWLEDGEMENTS During the course of this PhD, I was funded by a USQ Higher Degree Scholarship. The Faculty of Science and the Department of Nursing also provided finances for conference travel, opportunity for student-supervisor contact whenever possible, and everyday practical assistance. I would like to personally express my thanks to the following mothers and midwives for so generously giving their time and sharing with me, their experiences of childbirth and midwifery practice. Thanks too, to their families for their consent and cooperation. Without their invaluable contribution this research would not have been possible. Mothers (pseudonyms) Ellie Caroline Arline Megan Judy Brenda Maree Kay Midwives (pseudonyms) Gemma Bev Ann Ruth Katie Kerry-Anne Diane Madonna Thank you to the administrative staff in the Faculty for their skilful assistance and friendship. Gratitude is also extended to both academic staff and students within the Faculty for their support. A special thanks is extended to Mrs Ruth Hilton, Manager of Research and Higher Degrees for her practical and emotional support during my time of grief.
v My heartfelt thanks go to my family and friends for their understanding and support. In particular, thanks to my father who died before he could see the project completed, for his patience and love, and to Ms Jacqui Conn for her generosity and encouragement throughout the duration of this project. To Hebe my beagle, I promise more walks and attention now. Finally, thanks to my principal supervisor, Associate Professor Don Gorman, and associate supervisor, Professor Jennifer Watson, for their assistance. Dr Gorman has been generous and flexible with his time, and his professional guidance and criticisms have been integral to the success of this work. I am also grateful to Dr Peter Isaacs (Centre for the Study of Ethics, School of Humanities and Social Science, QUT) for his academic guidance, constructive discussions and continuing collegial support, and to The Reverend Illtyd Loveluck for his editorial assistance.
vi CONTENTS ABSTRACT...I CERTIFICATION OF DISSERTATION...III ACKNOWLEDGEMENTS... IV LIST OF TABLES... xi LIST OF FIGURES... xi SECTION A - THE RESEARCH BACKGROUND... 1 Chapter 1: THE RESEARCH BACKGROUND... 2 1.1 INTRODUCTION... 2 1.1.1 Looking for the billabong: How I came to be in this ethical place... 2 1.1.2 The metaphor...8 1.2 WAYS OF SEEING: WAYS OF ACTING...10 1.2.1 The social construction of our world...10 1.2.2 The nature of practice...11 1.3 NATURE OF CONCEPTUAL THEORETICAL RESEARCH...12 1.4 SITUATING THE RESEARCHER...15 1.4.1 Midwifery practice in Australia from 1970s to 1990s: a personal perspective...15 1.4.2 Medicalisation of birth and the role of midwives...18 1.5 RESEARCH PROBLEM...20 1.6 AIM OF THE STUDY...21 1.7 RESEARCH QUESTION...22 1.7.1 Thesis statement...22 1.8 DEFINITIONS AND LIMITATIONS OF THIS RESEARCH...22 1.8.1 Definitions...22 1.8.2 Limitations of the research...27
vii SECTION B - HOW EXISTING ETHICAL FRAMEWORKS HAVE DIRECTED ETHICS FOR MIDWIFERY... 28 Chapter 2: ON THE BEATEN TRACK - MAINSTREAM ETHICS, MEDICALISATION AND MIDWIFERY... 29 2.1 INTRODUCTION...29 2.2 THE NATURE OF MIDWIFERY PRACTICE...30 2.3 THE INFLUENCE OF MORAL PHILOSOPHY, AND NURSING ETHICS...34 2.3.1 Moral philosophy and mainstream ethical frameworks available to midwives...34 2.3.2 Why midwives would be turning to mainstream ethical frameworks...41 2.4 CONCLUSION...55 Chapter 3: THE FALSE TRAIL - A CRITIQUE OF BIOETHICS AND THE PROBLEM- SOLVING APPROACH FOR MIDWIFERY ETHICS... 58 3.1 INTRODUCTION...58 3.2 BIOETHICS - ITS DEVELOPMENT AND CRITICS...61 3.2.1 Casuistry and context...64 3.2.2 Quandary or dilemmic ethics...67 3.2.3 Contextualism...68 3.3 A CRITIQUE OF THE NORMATIVE, DILEMMIC/ PROBLEM-SOLVING APPROACH OF BIOETHICS FOR MIDWIFERY...73 3.3.1 When the situation is disembedded...74 3.3.2 When the subject is disembodied...78 3.3.3 Intellectualist principles...80 3.3.4 Ethical good, social control...82 3.3.5 Dilemma and problem focused ethics...85 3.4 CONCLUSION...88 Chapter 4: MIDWIFERY'S DETOUR THROUGH NURSING ETHICS - A CRITIQUE OF PROFESSIONAL CODES AND INFLUENCES THAT SHAPE THE MIDWIFERY ETHICS DISCOURSE... 90 4.1 INTRODUCTION...90 4.2 TRADITIONS OF A PROFESSIONAL PRACTICE, INSTITUTIONALISATION, AND APPLICATION OF A CODE...92 4.3 A CRITIQUE OF ETHICAL CODES...94 4.3.1 Perceived Strengths of Codes...95 4.3.2 Perceived Weaknesses of Codes...97 4.4 HOW ETHICAL DISCOURSE IN MIDWIFERY IS SHAPED...105 4.4.1 Educational curricula and their ethical orientation...107 4.4.2 The workplace setting and institutional influence...109
viii 4.4.3 Text books, journals and conference presentations: their ethical orientation...116 4.5 CONCLUSION...123 SECTION C - RE-ORIENTING AN ETHIC OF MIDWIFERY: MIDWIFERY WAYS OF SEEING [AND BEING ] IN THE PROFESSION 125 Chapter 5: OFF THE BEATEN TRACK - PHILOSOPHICAL FOUNDATIONS AND METHOD FOR THE RESEARCH... 126 5.1 INTRODUCTION...126 5.2 VALUES AND ASSUMPTIONS OF FEMINIST THEORY EPISTEMOLOGY AND ONTOLOGY...129 5.3 FEMINIST APPROACH TO ETHICS AND CONSTRUCTIVIST RESEARCH IN MIDWIFERY...137 5.3.1 A feminist approach to ethics in midwifery practice...137 5.3.2 A feminist-constructivist approach to research in midwifery practice...154 5.4 METHOD OF GATHERING INFORMATION: PERSONAL NARRATIVES...162 5.4.1 Values and Assumptions of Narrative Inquiry...163 5.4.2 The ethical implications of doing feminist research...166 5.4.3 The feminist narrative method of inquiry...168 5.5 THE PEOPLE IN THE STUDY: ORIGINAL OWNERS OF THE KNOWLEDGE...177 5.5.1 Profiles of the women who participated in the research...177 5.5.2 The informant-researcher relationship...178 5.6 CONCLUSION...183 Chapter 6: THE ETHICAL VOICE OF MOTHERS AND MIDWIVES - FINDINGS AND ANALYSIS OF NARRATIVES... 185 6.1 INTRODUCTION...185 6.2 IDENTIFICATION OF THEMES AND CONCEPTS...188 6.3 CENTRAL THEME...193 6.3.1 Power in relationships...193 6.4 THEMES AND CONCEPTS SHARED BY MOTHERS AND MIDWIVES...207 6.4.1 Institutional dominance...208 6.4.2 Values conflict...228 6.4.3 Being with woman...240 6.5 WAYS OF SEEING...289 6.5.1 Metaphors used by mothers and midwives...289 6.5.2 Personal transformation...292
ix 6.6 CONCLUSION...295 Chapter 7: CHECKING OUR COURSE - VALUES AND PHILOSOPHICAL FOUNDATIONS OF THE MIDWIFERY PROFESSION, AND DISCUSSION OF FINDINGS300 7.1 INTRODUCTION...300 7.2 THE MIDWIFERY PROFESSION'S VALUES, REFLECTED IN DISCOURSE...302 7.2.1 The philosophy and theory behind midwifery practice...302 7.2.2 Practice decisions and conflict between work place and personal/professional ethics..337 7.3 THE MIDWIFERY RELATIONSHIP...343 7.4 CONCLUSION...346 Chapter 8: PASSING BY THAT BILLABONG, GHOSTS MAY BE HEARD FROM OTHER TRAVELLERS LITERATURE ON WOMEN S EXPERIENCES, AND DISCUSSION OF FINDINGS... 351 8.1 INTRODUCTION...351 8.2 THE BIRTH: WOMEN S EXPERIENCES...352 8.3 THE MIDWIFE S APPROACH: WOMEN S EXPERIENCES...363 8.4 CONCLUSION...369 SECTION D - TRAILBLAZING TO MAP A NEW ETHIC FOR MIDWIVES 376 Chapter 9: FROM PRACTICE ESTATE TO THE BILLABONG AND BACK, NOW A RETURN JOURNEY TRAVELLED IN TANDEM IMPLICATIONS, RECOMMENDATIONS, AND CONCLUSIONS... 377 9.1 INTRODUCTION...377 9.2 A MAPPING STRATEGY FOR CONSTRUCTING A MIDWIFERY ETHIC...378 9.2.1 The nature of engagement in ethical responses and relationships...378 9.2.2 The centrality of the concepts which emerged from interviews and literature, in an ethic of midwifery...383 9.3 IMPLICATIONS AND RECOMMENDATIONS...386 9.4 CONCLUSION...388
x REFERENCES... 390 APPENDICES... 406 APPENDIX I...406 Code of Ethics for Midwives in Australia (ACMI)...406 APPENDIX II...410 An explanatory statement of the research for informants...410 APPENDIX III...411 Written consent form...411 APPENDIX IV...412 Privacy agreement for typists...412 APPENDIX V...413 Validation letter to informants...413 APPENDIX VI 414 Participant Profiles....414
xi LIST OF TABLES TABLE TITLE OF TABLE PAGE NUMBER 1 Representation of data organisation process using the theme Institutional Dominance for the midwife group, as an example 191 2 All themes and sub-themes identified in participants' narratives 3 A midwifery ethic based on the mother-midwife relationship 192 385 LIST OF FIGURES FIGURE TITLE OF FIGURE PAGE NUMBER 1 The use of power in mother-birth attendant relationships, and the effect on personal/professional values of these mothers and midwives 196