The limits of choice : how community midwives negotiate choice in and of their practice
This study explored the ways in which community midwives negotiate competing discourses when supporting choice in pregnancy and birth. The ways in which choice was presented to pregnant women by NHS Trusts providing maternity services, via their information leaflets and the websites that host them, offered an indication of how such organisations conceptualised pregnancy and birth, providing the context in which the community midwives practised. Foucauldian discourse analysis was undertaken of the leaflets and websites, illustrating the discursive structures in which community midwives worked. Interviews with community midwives explored the ways in which they negotiated competing discourses when supporting women to make choices in their pregnancy and birth. In Leaflet 1 and its host website, a dominant medical discourse was identified. The power/knowledge of this discourse could be traced to a medical philosophy that believed that pregnancy and birth are risk laden activities, that women’s bodies are likely to fail and therefore require medical input to manage. In this discourse women are discursively constructed as patients, which repeats and renews medical dominance. Leaflet 2 and the associated website demonstrated a midwifery discourse, which recognised pregnancy and birth as a social as well as a biological construct. In this discourse, the community midwife is discursively constructed as one who understands and supports physiologically normal pregnancy and birth and takes responsibility for recognising any departure from the norm and advising and referring on as required. Crucially in this discourse the woman’s autonomy is recognised and her choices, based on her perceptions of risk, respected. The discursive construction of the leaflet and website place the midwife in the community, not just the spaces of the home, but the wider geographical community. The interviews with the community midwives illustrated the challenges and barriers they encountered in providing information to support truly informed choice and at the same time working with competing discourses. The midwives valued working in the community, believing that this gave them greater insights into the women’s lives and more freedom to practice midwifery. The close proximity to the lived experiences of women enabled them to appreciate that choices were often limited by the socio-economic circumstances. This insight however could also lead the midwife to shape options based on her perception of what women might find acceptable. Choices were also influenced by what the midwives knew was possible from an organisational perspective. Through the application of clinical guidelines, the community becomes a disciplinary space where activity can be measured and managed. The midwives wanted to support women to choose care that was right for them but felt personally and professionally vulnerable when women made choices that they were not comfortable with. The woman’s hand-held notes became an object of disciplinary control as they recorded consultations with women in order to create an auditable account in the event of an adverse outcome.Their relative isolation from the Trust was viewed positively by the midwives but also resulted in the loss of their professional voice. This was seen in the ways they did not advocate for women’s choices or did not articulate the community midwifery contribution to care. A discursive transformation from a midwifery discourse to a medical discourse was located, identifying a community midwifery risk discourse. The power/knowledge of the discourse is located in a midwifery discourse with a codicil of risk. The midwives are constituted as practitioners who perceive themselves to have a degree of autonomy but whose practice, and therefore their ability to offer and support women’s choices, is constrained by a risk discourse which governs their thoughts and conduct. This risk discourse is amplified by their location in the community, and where the medical discourse identifies a disciplinary space.
Networked Digital Library of Theses and Dissertations