THE CHANGING CONTEXT

At an individual level, becoming a mother changes lives in all sorts of ways. Journeys into motherhood have implications for our sense of who we are, as our old recognisable selves can become subsumed within the new identities associated with being a mother and motherhood. The enormity of the changes that transition to motherhood can reap should not be underestimated, and often require adjustments on the part of all family members (Miller 2000a). At a wider level, social changes have translated into mothering occurring in different places and at different times in women’s lives. Family size has also been reduced, and over a third of births occur outside marriage. The significance of mothering to women’s lives, within the context of changed educational opportunities for (some) women and the resulting shifts in patterns of employment, also has implications for the ways in which we think about mothering and motherhood. There has been an increase in the number of single mothers and others who follow ‘non-traditional’ ways of living and parenting, as well as an increase in the number of women choosing to remain childless (McRae 1999). In all post-industrial societies, contemporary mothering arrangements are more diverse, yet often remain unrecognised in areas of family policy and practice, which continue to assume traditional family types (Duncan & Edwards 1999). This is apparent in relation to mothers whose mothering challenges stereotypes. The experiences of mothers who have found themselves to be marginalised have been studied in recent years – teen mothers, immigrant mothers, lesbian mothers, homeless mothers, welfare mothers and incarcerated mothers (Garcia Coll et al 1998). These ‘types’ of mothers serve to emphasise the way in which particular ideas about ‘good’ mothering and who constitute ‘good’ mothers are reinforced. This morally charged context can make it difficult for mothers experiencing ‘normal’ difficulties associated with pregnancy and early mothering to speak out, and so needs may remain unvoiced. Yet, although feminist and other research has pointed to the diversity of contemporary mothering experiences, services around childbirth in many western countries continue to be provided in particularly uniform ways (Treichler 1990, Glenn et al 1994, Barclay et al 1997, Garcia Coll et al 1998, Chase & Rogers 2001).

A further feature of contemporary society in which mothering is experienced and midwifery services provided is linked to perceptions of risk. Social scientists have argued that changes in late modern societies have led to increased perceptions of risk as a result of old traditions and habits no longer providing the certainties for us that they once did (Giddens 1991, Beck 1992, Beck & Beck-Gernsheim 1995, Lupton 1999). In relation to reproduction and childbearing, perceptions of risk have led women increasingly to look to those with expert knowledge – doctors, midwives and other health professionals – to provide guidance (Lupton 1999). In this rapidly changing context, the childbearing experiences of previous generations have become less relevant as trust is placed in those with professional, expert skills. Clearly, increased perceptions of risk, together with other changes such as those in family formations, have implications both for women’s expectations and experiences of pregnancy and childbearing and for midwives supporting and meeting their needs. This ‘moral minefield’ provides a powerful backdrop against which women take reproductive decisions and make ‘choices’ (Murphy 1999). The changing context, then, in which reproduction and childbearing take place is culturally, morally and socially shaped and experienced by women in different ways: experiences are far from universal (Davis-Floyd & Sargent 1997).

BEING WITH WOMEN: MIDWIFERY PRACTICES

Historically midwives have had the main responsibility for providing care to childbearing women: to be ‘with woman’ (Kitzinger 1988:1). However, in recent times the development of more formal and regulated health services in the West, together with the medicalisation of childbirth, has led the midwife’s role – and areas of practice – to shift. According to Kitzinger, ‘in childbirth today the Obstetrician usually stands centre-stage’ (1988:1). Although there have been more recent changes in relation to where and how services are provided to childbearing women, with an increased emphasis on team work and community-based service provision, perceptions vary of the autonomy of midwives as independent practitioners. In a study by Sikorski et al (1995) it was reported that obstetricians did not tend to regard midwives as independent practitioners – whilst most midwives did in fact see themselves in this way. In many ways midwives can find themselves in the difficult position of being both with women and providing care and support whilst at the same time negotiating the contours of medicalisation and hierarchical working structures. The midwife’s independence as an autonomous practitioner can be hard to assert in this challenging context.

In terms of service planning and provision, the early 1990s in the UK were characterised by a series of investigations, reviews and reports into the delivery of maternity services (National Audit Office 1990, Winterton Report 1992, DH Expert Maternity Group 1993 Changing Childbirth, National Health Service Management Executive 1994). These resulted in policy shifts that emphasised greater autonomy for midwives, hand in hand with more community-based ‘woman-centred participatory care, accessible and appropriate services and effective and efficient care’ (Dowswell et al 2001, Wrede et al 2001:32). Recent policy changes have called for the delivery of maternity services that promote continuity of care and meet women’s needs in a way that encourages participation and more recently partnership (DH 2003, Delivering the Best). For midwives, being with women in recent years has increasingly involved practice that is evidence based, and focused on meeting women’s needs in the community. Although widely welcomed, in practice the implementation of such policy recommendations has not been straightforward. Policy recommendations do not always map neatly onto existing working structures or individual lives. For example, as Wrede et al have observed (2001:33), ‘continuity of care has not always resulted from the establishment of midwife schemes because team midwifery is more popular among midwives than is caseload midwifery’. And whilst there have been real attempts to change and improve service delivery, Page and Sandall have recently noted (2000:673) that ‘standard maternity care still consists of fragmented relationships between caregivers and families, confusion about the role of the midwife in relationship to the obstetrician and GP, and an increasing series of screening tests throughout pregnancy, labour and the postnatal period’. Unfortunately this confusion is also evident in some of the accounts of women receiving maternity care (Miller 2000a). In the following section the research approach that provides the empirical data for this chapter is outlined.

MAKING SENSE OF BECOMING A MOTHER

It has recently been noted that ‘despite the large volume of literature on maternity care, the amount that is known about midwives’ contribution to care and what women think about it is limited’ (Dowswell et al 2001:99). The small-scale, longitudinal qualitative study reported here makes a small contribution to placing women’s experiences of receiving care in the academic and professional arena. The study explored the ways in which women experience and construct narratives of their transition to first-time motherhood (Miller 1998, Miller 2000b). The 17 participants in this study were all white, first-time mothers-to-be, who were in employment at the time of confirmation of their pregnancy. The sample was accessed away from formal health services, initially using the researcher’s own social networks and then snowballing techniques. In-depth interviews were carried out on three separate occasions; at 7-8 months antenatally, 6-8 weeks postnatally and finally 8-9 months postnatally. A total of 49 interviews were undertaken and these were followed up by a short postal questionnaire. The mean age of the participants was 30 years at the time of the first interview. Analysis of the data focused on the ways in which individuals make sense of their experiences through narrative construction (Miller 2000b). The research approach did not set out to generate findings from which generalisations could be made, but rather to produce rich data from which theory could be generated. The findings add to a limited but growing body of qualitative research on women’s experiences of reproduction and childbirth. In many ways this sample conforms to stereotypes that are held in wider society about those who are positioned as ‘good mothers’; these women were white, predominantly middle-class and either married or in partnerships. Yet the data reveal how diverse and complex their experiences of becoming mothers were. In the following sections lengthy extracts from the antenatal and early postnatal interviews will be used to show the ways in which this group of women construct their needs and experience care. The tensions that can arise from care which is shaped by wider policy concerns, and grounded in sometimes entrenched professional practices – often task-based and routine – and personal experiences which are individual and increasingly diverse, are explored below.

PRACTICES AND PERSONAL EXPERIENCES: THE ANTENATAL PERIOD

In the UK, preparation for motherhood continues to be located within a highly developed system of antenatal care that is located within a formalised, medical context: the clinic and the hospital (Tew 1990, Oakley 1993, Miller 1995). Indeed it could be argued that the hospital is now culturally accepted as the ‘natural’ place to give birth in many developed societies where everyday aspects of life are increasingly medicalised and expert, authoritative knowledge sought (Foster 1995, Davis-Floyd & Sargent 1997). Technological advances have also contributed to claims of expertise and provided practitioners with the tools to monitor progress during pregnancy and childbirth, for example screening. It is interesting then, but perhaps not surprising, to note that attempts to redefine women as consumers of maternity care with a right to choice, control and continuity, have faltered. Indeed one conclusion from a recent review of the literature on midwifery and community-based care was that in the antenatal period ‘offering women choices about care may be problematic’, and this was because women ‘may not be aware of what different options put to them entail’ (Dowswell et al 2001:98). Supervision and medical regulation continue to characterise service delivery in some areas, rather than more participatory styles of care that some policy initiatives had called for. But this ‘supervision’ is largely welcomed by women who derive reassurance from, and want, expert guidance and do not feel competent in making choices about something they know very little about. For most women expecting a child – especially a first child – making use of antenatal services and seeking professional advice is regarded as the appropriate way to diminish risk and to prepare responsibly and safely. There is some irony then that the antenatal period is experienced as less certain and more complex at a time when biomedical, expert knowledge has apparently provided greater scientific certainty than at any time before (Lupton 1999).

A key part of the midwife’s role involves supporting women in their preparation for childbearing. In relation to information giving and care in the antenatal period, the findings from the qualitative study confirmed that women expected this to be provided by those they perceived to be expert. The women’s antenatal accounts were characterised by engagement with, or in some cases the handing over to, doctors and midwives. For example, whilst the women all referred to gathering information about pregnancy and childbirth from relatives and friends, these were regarded as less reliable – less expert – than that provided by health professionals, as the following extract shows. (All names and any other identifying features have been changed.)

Similarly, this theme of wanting, and seeking out, expert advice is continued in the following extract in which Angela talks of her wishes in relation to feeding, but within the context of having to seek confirmation from the midwife.

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