slipping through the chasms: the experiences of women

SLIPPING THROUGH THE CHASMS: THE EXPERIENCES OF WOMEN

DENIED MIDWIFERY CARE

By

NICOLE HILL

Integrated Studies Project

submitted to Dr. Gloria Filax

in partial fulfillment of the requirements for the degree of

Master of Arts – Integrated Studies

Athabasca, Alberta

February, 2015

S l i p p i n g T h r o u g h t h e C h a s m s | 2

Abstract

Birth is a universal event in human reproduction. Although universal, birth is impacted by an

abundance of personal, social, and cultural factors, one of which is the type of maternity care

provider who attends women during prenatal, birth, and post-partum care. Midwifery is a form of

maternity care growing rapidly in popularity in North America after falling out of favour with

the rise of modern, western medicine in the 19th century. Today the demand for midwifery in

many places, including Alberta, Canada, exceeds supply. Presently, there is little research, which

speaks to the experiences of women who are denied midwifery in circumstances where the

supply fails to meet demand. Qualitative interviews are utilized here to explore the reproductive

experiences of five women in Edmonton, Alberta, Canada who were denied midwifery care.

Themes from their experiences including motivation for midwifery, prenatal care, birth, post-

partum care, and other topics are presented here. A discussion of the results with specific

attention to the concept of respect follows along with consideration of the study’s limitations.

Recommendations for action and for future research are also presented.


Acknowledgements

The author acknowledges the invaluable support of her supervisors and peers, particularly this

project’s supervisor, Dr. Gloria Filax for her guidance early on. The author’s family made the

report possible with their support and patience. Athabasca University’s Graduate Student

Research Fund financially supported the project. Finally, the author would like to acknowledge

all of the women who participated in the study, the numerous more who volunteered, and all of

the others who fell into the chasms.


Contents Abstract ........................................................................................................................................... 2

Acknowledgements ......................................................................................................................... 3

Introduction ..................................................................................................................................... 5

Background ..................................................................................................................................... 6

Midwifery and Maternity Health Care ........................................................................................ 6

Related Research ....................................................................................................................... 10

Theory ................................................................................................................................... 16

Results ........................................................................................................................................... 22

Women ...................................................................................................................................... 22

Categories ................................................................................................................................. 23

Why midwifery? ................................................................................................................... 23

Prenatal Care ......................................................................................................................... 26

Birth ...................................................................................................................................... 32

Post-partum ........................................................................................................................... 38

Other ..................................................................................................................................... 42

Discussion ..................................................................................................................................... 49

Respect ...................................................................................................................................... 51

Information and (Re-) Education .............................................................................................. 53

Limitations ................................................................................................................................ 54

Concluding Thoughts .................................................................................................................... 56

References ..................................................................................................................................... 58


Introduction

In North America, notions of pregnancy and birth exist within discourses including

human rights, ethics, technology, gender, sex, politics, varying and often conflicting notions of

‘normal’, economics, risk, fear, knowledge, science, faith, and beyond. Discourse in this context

“sets the limits of what can be spoken and, more importantly, how something may be spoken of

… Discourses are thus an exercise of power” (Allan, 2011, p. 389). Reproduction, both as an

individual experience and as a cultural and social concept, is undeniably complex and engages

themes that connect with many other topics. Although reproduction is older than society itself, it

is undoubtedly subject to a range of popular opinion at any given time. A woman who becomes

pregnant, and potentially her partner and/or others close to her, depending on her circumstance,

is then quite likely faced with shifting from a spectator of reproductive discourses, to being

personally and intimately impacted and engaged by them. She may find herself with an array of

challenging choices to make, or in fact, the absence of choice, or anywhere in between. A

woman’s experience of reproduction is impacted by the ongoing, and often competing,

discourses surrounding reproduction and by her own unique identity which exists at the

intersection of any number of inequalities1; not only this, but the birth experience is also

impacted by who surrounds it and how the woman is cared for and treated during that time. In

this swirling vortex of issues and impacts, it may be easy to overlook the notion that, to

childbearing women and those connected to them, birth matters in distinct and important ways

compared to the professional, political, and administrative perspectives of care providers, policy

makers, and administrators who create, manage, and maintain the health care system. Then

1According to Baker, Lynch, Cantillon, and Walsh, “women are not just women; they may also be advantaged or disadvantaged by their class, age, ethnic origin, sexual orientation, disability, etc.” (2009, p.69). A woman’s reproductive experience is then likely to be impacted by her specific intersectional identity where gender crosses over any number of other factors.


again, if one takes a step back to consider birth, its’ potential to drive social change, its’

intensity, its’ unique place in human lives, it seems obvious that birth does matter.

Maternity care has a systematic influence on childbirth. In North America, maternity care

and perceptions of care are shifting. Midwifery, a traditional type of care women experienced in

pregnancy and birth, was cast out in the later 19th century, while medicalized birth, controlled by

physicians, rose to its place of power in the maternity care field (Parry, 2008, p. 788). In the late

1960’s and 70’s, impacted by the women’s health movement, midwifery began regaining

popularity (ibid). In more recent years the popularity of midwifery has and continues to grow

rapidly, so much so that in many locations, supply of and access to midwives cannot meet the

growing demand.

According to consumer group, the MaternityCare Consumers of Alberta Network

(MCAN), maternity care in Alberta is in crisis (de Jonge, Hill, & Summerfeldt, 2014). One of the

dimensions of crisis identified by the group is insufficient supply of and/or access to midwives to

meet consumer demand across the province (ibid, p. 22). This project explores and reports on the

experiences of women denied midwifery in Edmonton, Alberta, Canada. The background of

midwifery and maternity health care, related research, and relevant theory will be explored. In-

depth analysis will point to themes present across the experiences described beginning with the

motivation to seek midwifery and the denial of that care, through prenatal care and birth, to post-

partum care. Results will be discussed including recommendations, which might address issues

that women identify, as well as potential directions for future research.

Background

Midwifery and Maternity Health Care


The majority of women in Edmonton seeking a maternity care provider will opt for one

of two types of care: a midwife or a physician (either a general practitioner or an

obstetrician/gynecologist). Beyond these two options, women may opt to privately hire a

traditional birth attendant (TBA), who may have some combination of training and/or experience

attending births but is not registered as a midwife. Additionally, women may opt to free-birth

(also called unassisted birthing), meaning they birth their children in their own spaces without

the aid of any formal care provider. The rate of usage of TBAs and free-birthing in this

population is unclear. Within the local birth community it is obvious that some women

participate in these practices, but there is no indication as to how many women select these

alternatives.

Maternity care is seeing a resurgence of midwifery, a vastly growing alternative to the

medical model of care widely practiced across North America. Midwifery is gaining exposure in

the media (CBC News, 2014; George, 2008), in popular and documentary films (Epstein, 2008;

Poul, 2010), in pregnancy guide books (Murkhoff & Mazel, 2008), and in general in North

American culture and society. Having gone from the only form of care, to the fringe of maternity

care, midwifery is now garnering interest, support, and growth. Demand for midwives in Alberta

is growing so rapidly that there are more women seeking them than there are client placements,

leading to very long waiting lists, with many women birthing their babies before their turn at the

top of any list. In Alberta, midwives have been registered since 1992; prior to 2009, women paid

out-of-pocket for midwifery services (Alberta Association of Midwives, 2014). In 2009

midwifery became publicly funded by Alberta Health Services and since then has become freely

available for all Alberta residents (Alberta Health Services, 2014b). Midwives in Alberta attend

about 4% of all births (Alberta Association of Midwives, 2014).


The Alberta Association of Midwives (AAM) describes its recognition of the natural

process of reproduction, and the profound meaning this period can have for women and their

families (2014b). AAM members aim to enhance the reproductive process through respectful and

reciprocal relationships with their clients (ibid).

According to the Canadian Association of Midwives (CAM) (2009) the fundamentals of

midwifery include “woman and family centered care that meets individual needs, promotes the

health, normal process of pregnancy and birth, and values the profound meaning of the

childbearing experience in women’s lives” (1). The CAM (2009) describes three tenets of

midwifery:

1) Continuity of care; women know their providers by having contact with them through

pregnancy prior to birth;

2) Informed choice; women are supported in being the “primary decisions maker”

regarding their own care, with midwives contributing “their knowledge and evidence-

based recommendations in a non-authoritarian manner” during visits which “allow

adequate time for open, interactive discussion and education” (p. 1), and;

3) Choice of birthplace; women may elect to birth in or out of hospital (which includes

private residences and birth centres).

The fundamentals of midwifery share similarities with efforts to shift Canadian maternity

health care policy to provide more family-centered care (Levitt, Hanvey, Avard, Chance, &

Kaczorowski, 1995, p.14), however the three central tenets above are what distinctively set

midwifery care apart from conventional medical care. Women who birth in hospital may or may


not be acquainted with the provider who attends them in birth, depending on their physician’s

scheduling (physicians in Edmonton, for example, generally take shifts doing office care and

hospital care that decide their availability for births), and also how many physicians attend them

prenatally (some practices include many physicians and it may be difficult to meet them all over

the course of regular prenatal appointments – this was described by the women interviewed

below). The choices women make in conventional medical maternity care exist in a

patient/doctor relationship premised on the principal of informed choice, which carries differing

connotations than informed consent, a tenet of midwifery (discussed in more detail below).

Lastly, women cared for by physicians do not have a choice of birth location; they are only able

to birth with their provider in hospital as physicians in Alberta do not attend births outside of

hospital facilities.

The dissatisfaction expressed both by women themselves as well as other citizens, with

the number of women being denied midwifery care, is obvious from the outcry in media,

public rallies, and a wide array of activism online. There is currently no official or commonly

accepted data available confirming the number of women being denied midwifery. Further, it

is also unclear if women widely have a clear understanding of how midwifery differs from

physician-led care, and understand that it is a publicly funded, theoretically available option.

Pregnant women and mothers are done disservice by the public health care system when they

want, but cannot access a midwife, when the health care system does not research the extent of

this problem, and when the health care system does not ensure that all women are provided

with sufficient information to make informed choices about the type of care they wish to seek

out.


At the time this report is being written, efforts are being made by the Alberta Association

of Midwives and Alberta Health Services to establish projects that would permit tracking of the

number of women on midwifery care waiting lists (J. Laine, President of the Alberta Association

of Midwives, Personal Communication, December 15, 2014; G. Becker, Director of Midwifery

Services, Alberta Health Services, Personal Communication, December 15, 2014). Both Laine

and Becker recognize the challenges in attempting to track the number of women waiting for

midwifery care, including the fact that a single woman is likely to be on individual waiting lists

with multiple midwifery practices, and the requirements to comply to applicable privacy

legislation with regards to the confidential nature of waiting lists (ibid.). Both also point to

limitations inherent in a tracking system as it would exist; specifically, tracking waiting lists to

aid in the analysis of demand and need for midwives would not include the numbers of women

who are interested in midwifery care, but do not apply to be on those lists for any number of

reasons (ibid). Some reasons that women do not apply for midwifery care include a lack of local

midwives to provide care, inability to commute to a practice, awareness of how difficult it can be

to obtain a midwife and a perception of midwifery care as an unrealistic plan, lack of knowledge

of how to access midwifery or that it is a provincially-funded alternative, and discomfort at the

possibility switching providers mid-pregnancy. Once a tracking system is in place there will be

slightly more information available to access how many women are waiting. Unfortunately, as

Laine and Becker point out, the picture will still be far from complete.

Related Research

In recent decades there has been rapid growth in research related to motherhood,

women’s health, and reproduction. In their research on type of birth attendant and satisfaction,

Wilson and Sirois describe the medical model of maternity care as taking a “problem-


management” approach to maternity, which includes high frequency of interventions, reliance on

technology, resource use, and aggressive procedures when compared to midwifery (2010, p. 70).

In a study exploring the use of midwifery by Canadian women, Parry (2008) describes

medicalized birth as birth, which is pathologized as an illness: biological, individualized, and

managed by health professionals (p. 785). In a medicalized birth women are not agents, but

patients (ibid). It is important to differentiate the term ‘medicalized’ from ‘medical’. Medicalized

in this context speaks specifically to a process and mindset the transforms a birth, not necessarily

any specific set of tools or procedures which would differentiate a medical birth. A medicalized

birth is decided by the ‘how’ of the approach to care, not in the ‘what’ of specific procedures.

Women choosing a midwife as their care provider are found to score higher on natural

birth philosophy, health self-efficacy, egalitarian relationship style and openness (Wilson &

Sirois, 2010, p. 70). In contrast, women choosing an obstetrician for maternity care are more

likely to describe birth as risky (ibid). Viewing birth as a natural event is the most significant

difference between women opting for midwife-led births and those opting for physician-led

births (ibid).

Resistance to the medicalization of pregnancy, labour, and birth and to a larger scale, the

inequality women experience regarding their part in reproduction may be a strong motivating

factor in choosing midwifery (Parry, 2008). Parry identifies eight specific factors motivating

women to choose midwives over other providers:

perspective that birth is a natural event

continuity of care available from midwives

emphasizing woman-centered care


preference for the model of informed choice/shared decision making

inclusion of emotional care

professional ability of midwives

midwives’ family friendly policies and practices

degree of personal control available in the midwifery model of care (2008, p. 796-

800).

As a result of the choice of midwifery experienced as an act of resistance to the role

passive recipient of medicalized childbirth, women in Parry’s research described feelings of

empowerment stemming from exercising control, strength, and confidence (2008, p. 800).

Resistance in this context is not absolute, but complex, as participants recognized the role of

medical interventions in saving lives when needed, but continued to avoid them in their care

(ibid).

Informed consent is a relatively well-known health care term in Canada as both a

patient’s right and a physician’s duty to facilitate. Informed consent is the engagement of a

physician in full disclosure to a patient of any given procedure’s nature, function, risks,

alternatives, and likely outcomes, prior to carrying it out (unless the procedure is indicated by

immediate emergency concerns) (Canadian Medical Protective Association, 2013). As

mentioned above, midwifery is distinct from the medical model of care by virtue of its

incorporation of informed choice, in contrast with the conventional medical model’s informed

consent. In the context of health care, “the term choice suggests the power or opportunity to

choose actively among alternatives, whereas the term consent implies a more passive compliance

with direction provided by a higher authority” (emphasis is Spoel’s) (2007, p. 7). Informed

choice in midwifery stands out as being connected to feminist rhetoric including values of,


“egalitarian partnership, mutual respect and understanding, invitational rather than coercive

communication, reciprocal empowerment, interconnection, trust, and equal access to

information” (2007, p. 20). The use of different labels between midwifery, which generally

refers to women as clients (AAM, 2014), and medical care, which refers to its’ users as patients,

also demonstrates fundamental divergences.

Women in Canada cared for by midwives described themselves as being more satisfied

with their birth experiences than women who received care from physicians (O’Brien, Chalmers,

Fell, Heaman, Darling, & Herbert, 2011, p. 212; Wilson & Sirois, 2010, p. 80). An important

part of the high satisfaction rate is related to the philosophical fit between woman and provider

(Wilson & Sirois, 2010, p. 80). In circumstances where women seek out midwives based on the

type of care they expect to receive, and are denied that care, they are left with having a physician

as the only other funded and registered provider, who may very well not have a similar

philosophy, the connection between philosophical fit and satisfaction may be a source for

concern.

Women cared for by midwives were also described as being given more information on a

wide range of relevant topics including managing discomfort, expectations to have for pregnancy

and birth, and the possible risks accompanying given tests (O’Brien et al., 2011, p. 212).

Receiving more information sets midwifery clients up for a potentially different experience from

their physician cared-for counterparts, in terms of preparedness, confidence and knowledge, and

may further differentiate those two experiences in significant ways.

Postpartum depression (PPD) and post-traumatic stress disorder (PTSD) are

psychological disorders, which can occur in relation to or even as a result of pregnancy and birth.


The Canadian Mental Health Association (CMHA) explains that specific causes of PPD are

unknown, however, some factors connected to PPD include stressful events during or after

pregnancy, a mismatch of mothers’ expectation of birth and reality, and types of birthing

practices as potential causal factors related to PPD in some women (2012). PTSD can be related

to childbirth, particularly traumatic childbirth. Reynolds (1997) refers to PTSD occurring as a

result of childbirth as post-natal PTSD. Specific traumatic features of birth considered connected

to PTSD include extreme pain and a sense of loss of control (Reynolds, 1997). It is then quite

possible, based on the priorities and preferences of women who prefer midwifery discussed

above, that a woman denied midwifery and forced into another type of care could be at

additional risk for PPD and PTSD.

Different types of providers are also associated with differences in physical outcomes.

Women cared for by midwives are more likely to have fewer interventions in childbirth than

their physician-attended counterparts, with no additional negative impacts (O’Brien et al, 2011).

When interventions in birth do occur, those compound the risk for complications (Sutcliffe,

Caird, Kavanagh, Rees, Oliver, Dickson, Woodman, Paige, & Thomas, 2012). Midwife-attended

women also have higher rates of breastfeeding success than their physician-attended counterparts

(O’Brien et al, 2011). Breastfeeding is associated with an array of benefits including improving

infant health, improving maternal health, increased bonding time, added convenience,

affordability, and being environmentally friendly (Public Health Agency of Canada, 2009).

Being refused midwifery reverberates outward beyond birth to potentially impact breastfeeding,

bonding, mental and physical health of mother and infant, with those effects extending outwards

into many facets of life.


As mentioned above, the field of research on and related to maternity care has grown

significantly in recent decades. Despite this growth, there is no research available that directly

considers the impacts of the ongoing midwifery shortage in Alberta and other locations. The

research here seeks to fill that gap by exploring how women describe this experience.

Midwifery and medical maternity care differ significantly, as outlined above. Women

seeking midwifery possess specific motivations as well as particular views of birth and the

relationship(s) they expect to have with their provider(s). Taking these facts into consideration, it

seems that refusing women their chosen type of care and by default forcing them into an

alternative, is very likely to be a source of tension at best with the potential for much greater

negative impacts. Apart from the specific practices and style of care, midwifery is the only

recognized type of maternity care that affords women the opportunity to select their birth

location. If a woman cannot obtain a midwife and wants a registered care provider, she will be

forced to birth in a hospital.

In a long-term study, Forssén (2012) interviewed women decades after their births,

finding that the impacts of negative experiences described as “harsh and humiliating” (p. 1535)

continue to reverberate for the duration of women’s lives through feelings of failure, guilt and

shame, which continued throughout their lives (p. 1543). It is again clear that how one gives

birth and how one experiences that birth matters.

At the time this report is being prepared, the current contract between Alberta Health

Services and the AAM (which details the funding allocated for midwifery in the province) is

very nearly expired and a new contract is being negotiated (Alberta Health Services, 2014). As

demand continues to grow, it is questionable if a new contract will be able to catch-up with


consumer needs. This is true of urban centres and in communities outside of Alberta’s major

centres, many of which have little to no access to midwifery. Women denied midwifery care will

likely continue to fall into the chasms of maternity health care for some time. It is hopeful that

this research will provide avenues that could assist women in bridging gaps between physician

and midwifery care and provide women with the tools to climb out of these chasms in the

Alberta circumstance and beyond.

Theory

This research is informed by both equity and feminist theories discussed below. The issue

of being denied an otherwise publicly available type of maternity health care due to a demand

that exceeds the current health care systems capacity to supply it is an issue of inequality and

social injustice. With the current structure, inevitably, some women receive this type of care,

while others who also desire it and would choose it, do not. The differential that exists there

represents a systematic inequality that uniquely impacts women and groups of women.

Equity

In their writing on equality, Baker, Lynch, Cantillon, and Walsh describe the concept of

equality of condition, which aims “to eliminate major inequalities altogether, or at least

massively to reduce the current scale of inequality (2009, p.33). Equality of condition is achieved

through changing social structures, particularly those that dominate or oppress (ibid). In the

circumstance of some women being unable to access midwifery maternity care due to demand

that exceeds the health care system’s supply, to achieve equality of condition the health care

system is required to change. Equality of condition is further described as being about “enabling

and empowering people to exercise what might be called real choices among real options. . . In


the dimension of resources, it is about having a range of resource-dependent options that is of

roughly the same value as those of others” (ibid, p. 34). Baker et al. identify income and wealth

as key resources in the pursuit of equality of condition, but also include other resources including

the “right to public services” (ibid, p.36). It may be argued, that the difference between

midwifery care and physician-led care is nominal compared to the difference between receiving

any public maternity care and receiving none, and so whether with midwives or physicians,

women are receiving roughly the same care. However, as discussed above, there are significant

differences between the contemporary medical model of maternity care and the midwifery

model, as well as being associated with different outcomes in terms of interventions and the

added potential for additional complications as a result, and patient satisfaction, with far-

reaching and lasting impacts. Therefore, women who want midwifery care but are denied it do

not have the same prospect of well-being in their birth as women who are granted access to

midwifery.

In their breakdown of the various contexts of equality, Baker et al identify four

interacting key social systems: economic, cultural, political, and affective (2009, p. 61). Public

services (such as health care) exist in the economic system. The unavailability of midwifery care

as a resource may be interpreted as an economic inequality. As Baker et al. explain though, the

different social systems interact and “what makes structural inequalities so persistent is that

inequalities related to class, gender, disability, ethnicity, sexuality and so on are reinforced in all

of the key social systems” (ibid, p. 62). Particularly relevant in the case of maternity care are the

economic system, which contains the resources and the political system, which decides and

administers policy on the services. Women as a group are historically systematically

disadvantaged in both economic and political power and resources. It is not surprising then that


social inequalities are rampant in the present services available for maternal health care and

childbirth. The individuals most impacted by the inequality (women) are lacking in the political

power to drive any significant change within the health care or political sphere.

Feminist Thinking

As a generally uniquely female experience, physiological reproduction lends itself to the

application of feminist theory. As discussed above midwifery is associated with feminist

thinking and the act of opting for midwifery care can itself be an act of resistance to

medicalization. In the research described above, themes related to patriarchy and feminism are

discussed, including notions of power struggle and control in the context of women’s bodies.

In The Politics of Women’s Bodies, Weitz (2010) describes how,

“[t]hroughout history, ideas about the nature of women’s bodies have played a dramatic

role in either challenging or reinforcing power relationships between men and women. As

such, we can regard these ideas as political tools and regard the battle over these ideas as

a political struggle” (p. 4).

Weitz (2010) outlines historical ideas of women as property, as less-than males, as weak-

willed and lacking in rationality and morality, as owing men sexual services or deserving of rape,

(p. 4-8). When women were able to make significant gains in addressing gender inequalities,

backlash would occur, for example during the nineteenth century when women were gaining

rights to vote and some headway into education and paid employment, a counter reaction

“combined new “scientific” ideas with older definitions of women’s bodies as ill or fragile to

argue that white middle-class women were unable to sustain the responsibilities of political

power or the burdens of education or employment” (Weitz, 2010, p.6). More recent forms of


backlash to women’s gains in equality have included pressures for women to conform to norms

of the shape and appearance of their bodies, the medical definition of premenstrual and women

in menopause as ill, and anti-abortion rights (ibid, p. 9). Regarding maternity specifically, Weitz

describes the occurrence of forced caesarean sections on women (particularly in marginalized

groups) as well as the notion that physicians ‘know best’ about women and infant health, as

opposed to the knowledge and perspectives of women themselves (ibid, p.11).

In the 1960’s and 70’s activists engaged in movements on women’s health. The women’s

health movement focused on women’s reproductive rights under the conception that gaining

control over their bodies would pave the way for equalization in other areas of education and

politics (Baird, 2009, p. 11). “The medical establishment was thought of as patriarchal,

authoritarian, racist, and demeaning to women in that women’s concerns were not taken as

serious concerns (ibid.). During this time women worked at consciousness-raising and

developing critical assessments of health care systems; regarding childbirth specifically, women

saw the development of birth centres and the emphasis of natural and home birthing, growing

popularity of midwife-assisted deliveries, and alternative birthing methods as a reaction to the

medicalization of childbirth that had occurred over the twentieth century (ibid). During the

1990’s the women’s health agenda resurfaced and extended beyond reproduction to include

violence against women and increased attention to women and women’s health concerns in

research (for example, in developing the field of breast cancer research)(ibid, p. 9).

In “Contested Bodies, Contested Knowledge: Women, Health, and the Politics of

Medicalization”, Morgan (1998) describes the important work of the feminist contestation of

women’s bodies and knowledge. Morgan views this work is being split into two complex and

related projects; the first is “the (re)claiming of women’s subjectivity, women’s agency”, and the


second is the “(re)claiming” of women’s epistemic power (1998, p. 109). Regaining subjectivity

and agency is described as rejecting the “stereotypical gender norm of silence” by speaking out

on individual experiences, both those of healing which are more often and readily shared, as well

as others being told more recently, including those of pain, humiliation, violence, broken trust,

and fears (ibid, p. 109-10). In their ability to break the silence, sharing stories such as these are

considered “a political act” (ibid, p. 10). The second task of reclaiming epistemic power is

supported by women’s maintenance and access to stories of knowledge and collective groups

where women may share their knowledge. The research being conducted here seeks to amplify

the reproductive stories of women who have been denied midwives by shining a light on those

otherwise silenced experiences.

The Study

To understand the experiences of women denied midwifery care, women who have

experienced that scenario and gone on to deliver with another type of care provider were

interviewed.

Potential research participants were recruited through print and online calls as well as

word of mouth conversations to participate in the study. Initially, a larger recruitment effort was

planned to extend to health care offices and public facilities but after a more enthusiastic than

expected response from responders, further recruiting was deemed unnecessary. After an

advertisement was placed in a freely available local childbirth magazine available across the city,

and a request for participants placed in a local birth-related facebook group (along with

individuals sharing the information amongst their personal networks), the response and support

from volunteers was significantly larger than the study could include.


Participants were required to have sought out midwifery care in Edmonton, Alberta after

it became publicly funded in 2009 and subsequently been denied this care due to a lack of

available client spaces. To participate, women were required to be between 18 and 35 years of

age at the time of the denial and to be fluent in English. For their participation women were

provided a fifty-dollar incentive to reimburse them for their time and trouble.

A total of five participants were interviewed over the summer of 2014 in their homes.

The number five was chosen to ensure that multiple perspectives were included, while ensuring

that the detailed interview data remained manageable for this project. Interviews were recorded.

The interviews were qualitative and took a narrative approach (Byrne 2012; Griffin & May

2012), allowing participants to focus on what they deemed significant in their reproductive

experience. Qualitative and feminist research methodologies were employed here based on their

potential to provide rich, detailed, and complex data (Morris, 2002, p.26; Kirsch, 1999, p. 11).

The researcher approached the interviews from a feminist research perspective, placing high

priority on supporting the meanings women accord to their experiences and creating a space to

listen to women’s voices (Morris, 2002, p. 54).

Open-ended interviews, like those I will be conducting, are especially effective at

establishing rapport with interviewees, validating their concerns, values, and experiences, and

fostering a shared bond as women that breaks down the traditional hierarchy that sees researchers

in a position of power (Kirsch, 1999: 25-6).

The interviewer utilized a very loose guide, which included a range of topics to discuss,

specifically, participant’s motivation for seeking midwifery, their prenatal care experience, their

birth, their post-partum experience, and if they became pregnant again, would they also attempt

to access midwifery again. The structure of the interviews remained quite open and for the most


part, the interviews organically fell into a chronological approach that naturally addressed all of

the topics to be covered, with some exceptions as participants explained some elements of their

story out of order to contextualize other elements, or remembered elements that had happened

earlier but only became relevant later on in the narrative. Apart from the loose guide, the

interviewer also asked probing questions as needed during the interviews to explore elements of

the accounts. Essentially open interviews were employed based on their ability to access

individuals’ values, understandings, experiences, and opinions, which might be less available by

other means (Byrne, 2012, p. 208-9). Further, the flexibility and adaptability of qualitative

interviews is especially useful when discussing sensitive topics, which might be difficult to

discuss (which would include birth and injustices related to birth) (ibid, p. 210).

The interview data was analyzed using thematic content analysis (Rivas, 2012). Each

woman’s experience from pre-conception to post-partum and beyond was reflected upon both in

its entirety and through the categories created from the collective voice of all participants,

informed by both an interpretive phenomenological analysis (IPA) and narrative analysis

informed perspective (Griffin & May, 2012). Thematic content analysis is utilized based on its

ability to draw themes out of rich and complex data (Rivas, 2012, p. 367). In the analysis

process, attention was deliberately paid to maintaining awareness of the entire maternity care

experience of each woman and caution was taken to avoid losing the holistic message of each of

the narratives in categorizing the content.

Results

Women

The five women sharing their birth experiences lived a variety of circumstances. The

group includes women who received a denial for their first and only child, women with multiple

children with the denial of midwifery in different locations along their reproductive spans;


specifically, a denial in their first pregnancy with acceptance to midwifery in their second, the

choice of a physician for their first and a denial for their second leading to a homebirth with a

TBA, a collaborative care experience including midwives for the first and a denial for the

second, and a denial for a third child with limited experience with midwifery care in a previous

pregnancy. Factors such as ethnicity and income were not controlled for or included in this

exploratory research. In the interviews, the focus for the research was on the experience of the

pregnancy, birth, and post-partum for which respondents had been denied a midwife and

delivered under another type of care. However, in order to contextualize those experiences, any

and all related maternity experience before and/or after the denial was discussed. The categories

derived below arise only out of the descriptions of the birth for which the denial occurred. When

names of participants or their families are mentioned below, they have been replaced with

pseudonyms to protect participants’ privacy.

Categories

The phases included here rose organically out of the interviews themselves. The

maternity continuum includes prenatal care (the period from knowledge of pregnancy to before

labour), labour and birth, and post-partum (everything after a birth up to 6 weeks later – which is

when a midwife would transfer the care of a mother and infant back to a provider of the mother’s

choosing). To appreciate the complexity of these experiences, the categories are differentiated by

each phase of maternity from the motivation for midwifery, prenatal care, birth, post-partum

care, and other (which includes topics emphasized by interviewees that do not correspond to one

of the other phases).

Why midwifery?


The first topics broached in all interviews spoke to the motivation to seek out midwifery

care. Four interrelated categories of motivation were present in the responses as discussed below.

Women described reaching their motivations through their own experiences (both in previous

pregnancies, and in their own personal exposure to midwifery and maternity care) as well as

research, which included formal research of academic and health studies, online research, as well

as anecdotal research with friends, family, and online communities.

Intervention-free

Women described a desire to avoid unnecessary interventions based on trust in the ability

of their body to birth without intervention, to avoid exposure to medications, which might be

harmful, and to avoid interfering with the physiological birth process. Multiple women described

a desire “to be left alone” and the belief that pregnancy is a natural life event and not an illness to

be managed.

Respect

Why Midwifery?

Respect Intervention

-free

Power Relaxed,

low-key tone


Respect included the desire to have interviewee’s wishes valued, and to avoid fighting

with care providers regarding topics such as prenatal testing, how the birth ought to be handled,

what positions were appropriate for labour and delivery, the use of medications, the use of

interventions, and similar concerns. Women described previous birth experiences with

physicians during which their knowledge of their own bodies was disrespected through refusal to

accept the due dates women had reached based on the knowledge of their cycles, and how they

wanted to labour and birth based on their own bodily sensations, knowledge, and experiences.

Power

Power was discussed in multiple dimensions. The choice of physical birth location was

one form of power discussed. Since physicians in Alberta do not attend births out of the hospital,

a woman denied a midwife, who is then left with limited choice but to be attended by a

physician, is stripped of her power to choose her birthing location. Beyond that, participants also

discussed their ability to exercise power and control over their birth environment, including

being the driving force in their own labours, and excluding individuals (staff) who engaged in

abusive, disrespectful, or disruptive behaviours. Many participants described previous birth

experiences that included powerlessness or refusal by staff/physicians to respect women’s

agency and power. Being “brushed off” and “bullied” by staff and/or physicians was described

by all women with previous birth experiences. For their subsequent births women described

“wanting to avoid going to the hospital if at all possible”, “avoiding a repeat”, and “never

wanting to do that [a hospital birth] again”.

Relaxed, low-key tone


The tone of midwifery care was described as “more relaxed” and “low-key”. Tone was

described this way as a preconception held by women who had not received midwifery care, as

well as those who had experienced midwife care prior to denial, and then was also confirmed by

those who experienced it subsequently. Women described their appointment experiences with

physicians as rushed, and with physicians often having their “hand on the door”. In comparison

to physician appointments women described their appointment experiences with midwives as

having ample time for discussion, questions, and “chatting”. Tone as discussed also seemed

connected to the idea of midwifery as more relaxed in its approach to allowing birth to unfold

naturally, as opposed to a medical model which was discussed in terms of its readiness, even

implied as a perceived eagerness, to intervene.

Prenatal Care

Prenatal care includes all experiences with care prior to labour and birth. Some women

went through multiple providers over the course of their prenatal period, others were cared for by

a single provider for the duration, and others still had gaps in care during which they went for

periods of time with no care provider at all.

Negative

Emotions

Knowledge

Acquisition

Contested

Knowledge

Pressure &

Threats Poor

Relations

With

Provider

Prenatal Care


Negative Emotions

The negative emotions described by women began with their reaction to being denied

midwifery care. One respondent described her initial response as “disappointed, but I took it in

stride. . . I didn’t really think about it a lot again until near the end when [the doctors] were

pushing induction”. Other women describe the feeling after being denied midwifery as, “scary”,

“crushed”, “devastated”, “worried”, “very upsetting”, “frustrating”, and “stressful”. Negative

emotions were related to relations with care providers. One respondent who had some concerns

regarding her care provider relationship but otherwise had a positive relationship with that

individual outside of their professional arrangement, experienced mixed emotions (both positive

and negative). Some also described an initial hopefulness that they might be called from a

waiting list. One respondent described the process of figuring out all of the providers as stressful.

Throughout their pregnancies women experienced additional negative emotions when

dealing with their providers. When asked about their relationship with their care provider, all

interviewees described it as “frustrating”, and one even stated that, “it was frustrating all the

time”. Other descriptors of the care provider relationship included “stressful”, “disappointing”,

and “a pain in the ass”. One also described her feelings about prenatal care with her physician

(after being very briefly accepted into midwifery and then dropped due to overbooking) as “me

against the world”. Another respondent described feeling doubt and questioning if her and her

partner had made the right choices up to that point and a fear of being shamed for her choices if

she returned to her original physician to seek advice, support, or care.

Knowledge Acquisition


All women interviewed had done extensive research on pregnancy, birth, and care. After

being denied a midwife, many women did intense research to be especially prepared for birth in

light of having a care provider “who was not on board” with their wishes. This also included

naturally-minded child birth classes in some cases. Many women researched providers after

being denied a midwife and opted for general physicians over obstetricians based on the belief

that general physicians were less specialized and “the next best thing” to a midwife. Women also

sought perspective from local women about which specific physicians might be more supportive

of intervention-free births. One participant described research binders she created for herself and

her husband which they brought when interacting with their care providers so that they could

reference specific studies as needed to legitimize their wishes by proving they were based on

scientific evidence. While doing that, she pointed out that “it felt like we shouldn’t have to justify

it”.

One woman explained that once she was denied a midwife she “really took charge and

learned everything [she] could” knowing that she would have to go to the hospital. She felt that

the research would support her in having a birth that she, not the hospital staff, determined, and

would build up her own strength in that context. She described the research process as

“empowering” beyond birth and, along with her faith, as contributing to a great deal of personal

growth which stemmed from the entire pregnancy.

Contested Knowledge

Women described the challenges they experienced when attempting to share their

knowledge, perspectives, and concerns with their providers. These challenges existed when

mothers raised research, which they were basing their decisions on, and when mothers drew on

their own lived bodily knowledge in discussion with providers. Women described their own


reluctance to accept interventions pressured for by providers that they felt were not needed; “I’m

not going to let you do that [induce], because this pregnancy feels normal”. Multiple women

described doctors changing estimated due dates and their own resistance to those changes based

on their own records of their cycles and bodily knowledge; “They always brushed my dates off.

One time they tried to convince me my dates were wrong, and basically that I didn’t know my

own body”. Based on ultrasounds, providers often shifted women’s dates earlier, with one

woman describing a provider’s reluctance to accept her assertions that she felt labour would

begin sooner than the provider anticipated. One respondent described the perception of the

attitudes of staff as, “I was a civilian, so what did I know compared to doctors” (emphasis is the

respondent’s).

In one instance a respondent even described accepting the idea that provider’s knowledge

was more valuable than her own; “as a first-time mom, I’m assuming the doctors know what

they’re talking about”.

Pressure and Threats

The contestation of knowledge was sometimes accompanied by pressure and threats by

doctors, nurses, and other health care staff. Many women described pressure for induction of

labour, especially in instances where dates had been bumped earlier. This included doctors

becoming “pushy”, describing birth injuries and mortality in lesser developed nations, which see

some settings lacking access to interventions, as well as threats that, “basically, I was killing my

baby”. Another respondent was told relatively early in pregnancy that if she did not have an

induction, her baby would become stuck in birth and she would not be able to deliver. She did go

on to deliver vaginally without complication.


A woman stated about her obstetrician, “I felt like he was not going to do what I wanted

and something unnecessary was going to end up happening”, before leaving his care and seeking

out another provider. She also described fear of going into a hospital birth because of the

likelihood of a caesarean section if her labour did not progress “fast enough”. In her description

of her motivations for wanting a midwife, one respondent stated, “I went to a GP thinking that

they’re not getting anything from pushing me into a c-section. They’d be transferring care, so

they’d be less likely to do that”.

Pressure, threats, and “refus[ing] to accept [her] no’s” kept one respondent feeling

uncomfortable with going to her physician. One woman stated that she was resisting going to her

physician because “she’s very good at convincing me to do things I don’t want to do”. Some of

the women interviewed hired doulas to be with them as support in pregnancy, labour, and birth.

One stated that decision was to “try to counteract the medical angle and bring in the midwifery

angle”. While another stated, “I don’t need a doula to help delivering, but I need support to

stand up for what I want . . . it’s just dealing with the administration. I don’t want to be bullied.

The first physician I was with bullied me, and that’s not right”.

Poor relations with care provider

Strongly related to pressure and threats are the comments made by women about poor

relationships with their providers and health care staff. It is notable that different women

accorded different degrees of significance to the negative issues they experienced with providers.

One described issues with the professional relationship, but also a loving and longstanding

friendship with their provider. Some did not describe any positives to their relationship. Because

of negative experiences with providers, some women went periods of time with no provider


while they were seeking out a new one, hoping to receive a call from one of the midwifery

practices they were waiting on, or trying to explore their options.

Women described feelings of disrespect abundantly in their relationships with their care

providers. One source of these feelings stemmed from consistently waiting hours to see a

provider and being told by the administrative staff at a physician’s office that appointments are

booked every five minutes. The respondent who was told that explained, “I don’t believe that

five minutes is enough time for a quality interaction with a care provider”, and described

following her physician through the hallway asking him about her care after he left the room

while she was still attempting to ask a question. One care provider refused to read a woman’s

birth plan, and was described as stating, “just bring it with you, you never know who will be

there”.

Women were also disrespected by a lack of follow-through in which a provider did not

do what they said they were going to do in terms of access to diagnostic maternity care tools and

a couple of missed appointments that were never made up. Another woman explained that her

doctor was “induction happy” and regularly brought up inductions. “I kept saying, I don’t want

that, and she said, “okay, but. . .” I’d just nod and whatever. I told her what she wanted to hear

and knew that I was going to do what I wanted. . . I thought, “I just won’t show up, you just

won’t see me””.

Respondents described an array of insensitive treatment. When one woman was told that

she would not be able to breastfeed and cried at the physician’s office, the physician looked at

her “like [she] was off the hook, like [she] didn’t have to breastfeed now” (emphasis is the

respondent’s). A similar situation happened when a woman was told she tested positive for

Group B strep and was told she would have to have an IV to administer preventative antibiotics


during labour; “they looked at [her] like “why are you crying?”, and said “it’s okay honey, now

you’ll have to have the hep lock [IV] anyways, so if you breakdown and need drugs we’ll be able

to pump them into you faster”. In a subsequent pregnancy after a high-risk pregnancy, which had

ended in an emergency caesarean section, a woman discussed her previous births with her

physician; “Fin’s [her second child whose pregnancy culminated in the emergency surgical

delivery] birth was very exciting and she [doctor] just loved it. It was exciting for her. You could

just see it on her face, it would just light up. She wasn’t’ interested in Amelie’s (her first child

who had an uncomplicated vaginal delivery) story, it was boring”.

One interviewee described her own feelings of disappearing as an individual later on in

pregnancy: “Somewhere between 28 and 32 weeks it stopped being about me and I became his

host. . . I’ve never felt objectified and dehumanized like I did in pregnancy, and I didn’t expect

that at all”.

Birth

Birth here begins when a woman goes into labour and concludes shortly after the delivery

of her child. Five categories are presented here, all are highly interrelated, particularly

dissatisfaction with care and abusive behaviour including threats. However, a sufficient amount

of significant data existed to differentiate these two, so both are presented.

Power

Struggle Dissatisfied

with care

Abusive

Behaviour,

Threats

Part of the

System

Finding

Positive

Birth


Power Struggle

Women described the conflicts and tensions they had with doctors and nurses in the

hospital, with staff attempting to “get [women] to do what they [staff] wanted”.

“There was one moment, I still regret it. I was in control, but I let them have control for

a moment. I needed a break and they all yelled in concert at me to push, and I thought, “well, I

do want him out”, and I pushed and had a bit of internal tearing. And you think, well, could I

have prevented that if I listened to what my body was saying when it wanted a break?”

“I’m not upset, I got what I wanted. In the end he was born without drugs in his system. I

won, I really feel that”.

“When you’re going in with a natural birth plan, you just get that pushback”.

“I did what they wanted for a while, and then I decided [they] were being ridiculous and

I’d had enough of that”.

Dissatisfied with care

Women described their doubts regarding the knowledge of their caregivers when they did

not feel like they were receiving appropriate care, including when care providers did not follow

evidence-based practices. One participant received an epidural and when she was told that she

was 10 cm dilated and could push, she was so numb that she couldn’t feel anything. On the first

push, the catheter (needed when one has an epidural) became dislodged; “I remember someone

noticing. Then I pushed for five and a half hours”. In this case, eventually the nurses called in an

obstetrician with forceps because the birth was taking so long. “The obstetrician asked, “when is


the last time she peed?” They reinserted the catheter and resolved that problem and he was out

in thirty minutes”.

“The hospital in general was a series of people not doing things. . . At the time I was

focused on getting the baby out, but now it adds to my desire to not go to the hospital again. Not

wanting to deal with that again” (emphasis is respondent’s).

One respondent described frustration when staff treated her and her husband differently

when they were advocating for their birth choices. “When I said something, they kept pushing,

but when my husband said something they let up more often”.

After her denial of midwifery culminating in an induced birth, one respondent went on to

have an un-medicated birth attended by midwives. “After having an un-medicated birth, I can

say that the medicated contractions and labour are totally different. It changed the whole labour.

It was longer than it needed to be. I ended up with an epidural that I didn’t want and pushing

way longer than I should have because no one was paying attention”.

Part of the system

“It’s policy”, “you can’t decline this”, and, “there is no alternative, you just have to do

it”, were heard by multiple women interviewed when they questioned or refused a procedure, or

asked about alternatives to what was perceived as the ‘normal’ tests and procedures within the

medical model of care. Another respondent also stated “I referred to it as a system a lot”.

Women experienced navigating health care as a bureaucratic process and health care

workers as attempting to achieve women’s compliance by relying on the tendency to submit to

that bureaucracy. ‘Policy’ and ‘the system’ resulted in women submitting to sitting still in labour

despite discomfort to do so, accommodating unwanted continuous fetal monitoring, in restricting


the individuals who could be present with women in labour and where they could join women

which led to undue stress, in women being unable to refuse procedures because the indemnity

waivers that needed to be signed and were not readily available, in the inconvenience of signing

waivers with a brand new baby on a mother’s chest only moments after delivery, and in

submitting to procedures scheduled before a long weekend under the suspicion of physicians

guaranteeing themselves the weekend off of work. In all but one interview, the concern was

raised that it is more difficult to obtain a midwife in the final several weeks of the year because

all of the permitted funding is used up earlier in the year and/or midwives take fewer clients on at

the end of the year due to the holidays.

Abusive behaviour, threats

Women described an array of abusive behaviour they experienced at the hospital. It is

noteworthy that one respondent who had a homebirth with a TBA did not describe any kind of

abusive behaviour in her birth experience, other respondents described varying degrees

consistently enough to justify the existence of the category.

“His whole birth was just high pressure and threats, it’s not how I wanted it to go at all”.

Women described waiting for as long as possible to go into the hospital once they were in

labour to avoid pressure to accept interventions. One woman who arrived at the hospital shortly

before birthing her son stated, “I was resisting leaving to go to the hospital, because of that

threat over my head [stemming from her experience with providers in regular appointments]. . . I

got to the hospital and they accused me of panicking. But I wasn’t panicking, they were

panicking”. Another explained, “I was crossing my legs in the car. . . It was so embarrassing [in

the waiting room], I felt like a labouring cow. It was humiliating”. One respondent described the


nurses in the hospital as “always frantic, always rushing. They wanted you to do what they

wanted you to do, right now”.

“The nurses at the hospital were all angry at me because I missed the call to go in for the

induction. When I called back they were saying I needed to come in right now, and I was so

overdue, and basically, you’re killing your baby”. An interviewee described her mindset after

being pressured by nurses to leave the room: “I just kept thinking ‘down and out’, because

they’re gonna make me go and I’m gonna have this baby in the car or cafeteria or something”.

Another respondent explained about her nurse, “She kept telling me to lie down, I said “no”. She

said, “you’re gonna tear”. I said, “I don’t care” because I knew it was a threat to try to get me

to do what she wanted”.

Threats, both veiled and blatant were frequent in the accounts of women interviewed.

There were also descriptions of other abusive types of behaviour ranging from neglect, to

rudeness, to verbal abuse, to physical abuse.

“The nurses were constantly yelling at me to push or be quiet. . . They were horrible,

saying “you’re only 3cm dilated, you’re not going to have the baby today””. When the same

woman was resting in between contractions a nursed happened to walk into her room and say

“she’s not in labour, you can’t sleep when you’re in labour!” The woman described her feelings

as, “I was so annoyed, I didn’t even open my eyes”.

After a brief period of the time at the hospital, which included “a lot of back and forth

fighting with nurses and doctors” one woman described the absence of any excitement or

celebration from staff once her baby (her first) was born; “I think everyone’s entitled to that after

having a baby. It was dehumanizing on that level”.


“When I got into the room, the nurses forced me to shower, which I thought was weird.

They said it would help with pain. They stuck me in there and just left me there”.

A respondent described multiple attempts by a nurse to inject something into her hep-

lock, an IV which is inserted but locked and held in place to be used if needed. She explains that

her husband caught and stopped the nurses from adding medication to the IV multiple times. It

became increasingly obvious to them that the nurse was aware of their explicit instructions not

to, as she appeared to be trying to sneak the medication into the IV.

Physical abuse was also described, including a physician forcefully pushing a woman’s

vagina over her crowning baby’s head, causing tearing. As well as a nurse roughly manipulating

a woman’s body during labour, despite the woman telling the nurse she was being hurt and

asking her to stop.

Finding the positive

Some women described positive highlights in their hospital birth experiences. In

particular two interviewees each described one nurse in their experience who made a positive

difference for them. The first said about one of her nurses, “She gave me a motherly-type

encouragement. I appreciated her, but no one else. All the others annoyed me, they were yelling

at me to push or be quiet. . . She was the first one I met and the last one to leave”. The other

respondent stated, “The last nurse on was amazing . . . without her I think we likely would have

had a c-section”. This last nurse was described as very experienced, with a great deal of

knowledge of different pushing positions (despite a strong epidural); “She was persistent that we

would get this baby out and was willing to keep trying”.


Women expressed being accepting of their arguably negative birth experiences. “I’m not

scared of birth. I think my birth went as well as it could, given the setting and the people who

were in charge. . . Other than the tone, when you strip away all of that and just go by events that

happened, it went as well as it could.” “In hindsight it was the best I could do in that situation”.

“It wasn’t what I wanted. It was okay, I guess. It wasn’t tragic”. “At the time I said we did

everything we could. The epidural was fine. I don’t regret it, but I wish things had gone

differently”.

The phrase “little things like that” came up repeatedly in the interviews when women

described negative elements of their experiences, from being pressured into doing things they

were resisting, to having questions and concerns brushed off, to being told they did not have

choices.

Post-partum

Post-partum care includes the period of time after birth to six weeks afterwards. At this

point a maternity care provider would generally return care to a woman’s regular health care

provider. In most interviews, post-partum care received significantly less emphasis than other

phases of maternity care. There were two exceptions: in one case a mother developed significant

breastfeeding issues and in another it was discovered through an emergency episode that an

infant had an underlying health condition that was dealt with through emergency and specialized

care resources, not post-partum care resources.

Post-partum


Process the experience

The notion of processing birth or elements of birth came up repeatedly. Women described

processing particularly fearful elements of their experience when they believed their children

and/or themselves were at risk. Multiple women also described a “rose-coloured” view of their

births in the relatively immediate periods afterwards, followed by a more critical analysis, which

reframed the experience and resulted in the identification of issues with the care received. These

women described time and additional knowledge, both in the form of formal research as well as

sharing stories with other women, to gain understandings of different birth experiences. One

woman described her denial experience as teaching her “what [she] didn’t want”, as well as

“how fast [she] needed to call midwives”.

Processing was described as being challenging because of the time it takes to do, “and

then of course, you’ve lost contact with the doula and everyone”. Anger came up repeatedly as

an outcome of processing a birth experience, in response to how interviewees were treated

during their births.

Negative hospital experience

The negative hospital experience here, again, does not represent the experience of the

individual who birthed at home, who described her immediate post-partum time as “lovely”. All

women who were at the hospital after birth described the experience negatively. Women

described wanting to go home right away and feeling like they did not need to be there. The

Process the

Experience

Negative

Hospital

Experience

Negative

Provider

Experience

Focus on

Positive


disruption to sleep, with bright lights, noise, and nurses coming and going regularly, was

described as a significant issue by all. Women in hospital described often feeling harassed by

nurses regularly and under an unnecessary and unwelcome amount of surveillance. Women also

felt as though they were not trusted to reach out on their own if they did want assistance.

Additional concerns raised included nurses being unwilling to listen to women as patients

and failing to respect women’s refusals. One woman stated, “I don’t believe nurses listen [to

women] unless there is a doctor present”. She described her experience with nurses in hospital

as “frustrating” when they were repeatedly conducting testing on her baby despite her requests

for them to stop and in light of the fact that in the same circumstance in her previous birth her

first child was only tested once. Another respondent described frustration that despite all of the

harassment and surveillance at the hospital, no one noticed a very significant breastfeeding issue

that was raised by another care provider a few days later.

One woman described her disappointment at having to stay in a shared room after her

birth. This further negatively impacted both her and her infant’s ability to sleep and was

especially problematic since her partner was not permitted to stay with her and their new baby in

the shared room. In addition she “felt so bad for [her] neighbour”, a new mom after a caesarean

section who was not receiving adequate support from nursing staff.

Negative provider experience

There was relatively little care provider contact post-partum for most women. The

interaction most frequently discussed after the immediate post-partum period was that with

public health nurses. In most cases the interaction with public health nurses was not emphasized

positively or negatively. One woman mentioned her health nurse had been tolerable compared to


the one attending her in a previous pregnancy. Two women had more significant and involved

interactions with health nurses, which they described negatively. One woman was harassed by

public health nurses when she went into the facility to weigh her son a few days post-partum and

he was not gaining weight. Nurses right away urged her to give him infant formula. She resisted,

having similarly just had a hospital birth in which she was pressured to have interventions she

did not want or feel were needed. They called repeatedly and threatened the new mother, once

stating, “well, we don’t want to get social services involved . . . It wasn’t until a lactation

consultant, that I hired, asked me, “Why has no one said the word hypoplasia [reduced tissue, in

this context, mammary tissue, resulting in difficult providing a sufficient amount of milk] to

you?””(Emphasis is respondent’s).

Another respondent had extended contact with public health nurses when she and her

spouse contacted them to schedule their regular post-partum home visit after a home birth with a

TBA. The health nurses were not knowledgeable about birthing practices outside of the norms of

hospital or midwife-attended homebirth, or even the concept of a home water birth. The public

health nurse who came to their home required the respondent to contact her physician to make an

appointment while the nurse stayed in her home and watched her. The public health nurses then

continued to call both her and her partner on their phones regularly to check-up on them until the

date of the physician appointment; “It did get very annoying”.

Focus on the positive

The same respondent who had a TBA attended homebirth was pleased with her birth and

described it very positively. Another respondent who was in hospital spoke about the positive

nature of nurses in the post-partum unit in the hospital. She explained that “everyone was doing


the best they could with what they had” and although she “could have let herself be miserable”,

she focused on the positive “to get through the things that were driving [her] nuts”.

Other

Other includes topics that were emphasized by women interviewed that extended beyond

the existing topics.

Concerns with system

Other

Future

Plans Mentality

of

Physicians

Concerns

with

System

Willing to

Accept

Needed

Care

Recomme-

ndations Large

Scale

Social

Issues

Initial Lack

of

Knowledge Birth and

Social

Relations


Women raised multiple concerns relating to the health care system. All respondents but

one raised the concern that they believe midwives use all of the funded spaces up earlier in the

year, so near the end of the year it may be much more difficult to be accepted as a midwifery

client; it was also pointed out that this would allow the providers to take time off at the end of the

year around the holidays. If this is in fact the case, (and with four out of five interviewees

incidentally having births in the last few months of the year, the possibility seems at least

plausible), it is a significant and problematic inequality amongst would-be midwifery clients.

The business of birth is a twenty-four hour per day, seven days per week affair, and public health

care cannot ethically be less available during potentially less convenient times of the year.

Access to and funding of midwifery were major obstacles to midwifery for the women

interviewed. The publicly funded universal health care system was also criticized often, with

women describing a preference to pay out-of-pocket for care to get a midwife as opposed to

being denied access because funds/courses of care were exhausted earlier in the year. Women

also expressed a preference for a combination system, which would allow women who

wanted/could pay to be able to if public funding was unavailable. Returning to a private payment

or two-tiered system (permitting private payment for service once public funding is spent), both

bring the risk of additional inequality as well, leaving those who cannot pay without midwifery

care.

Participants also expressed surprise that the health care system is not more supportive and

encouraging of midwifery since it is generally considered to be associated with lower health care

costs, safe outcomes, and resulting in less reliance on hospital facilities, leading to better access

for individuals needing that advanced level of care. In terms of effective government spending


on public services and the significant demand for these services, the surprise expressed by

participants seems warranted.

Mentality of physicians

Some participants mentioned sympathizing with physicians who regularly see “some

really bad stuff”, in terms of rare but serious, even fatal, outcomes. Women expressed an

understanding that “if all you see is high-risk births than all births become high-risk” and “if

you’re a surgeon, you see surgery”. Respondents expressed understanding of the “tunnel-

vision” the doctors may develop, but also wished for physicians with a wide range of experience

to support normal, non-intervention births.

Large scale social issues

Interviewees described a number of larger scale social issues that were present in their

maternity care experiences. One respondent identified that “huge issues got on my radar just

because I had a baby”.

“It seems like every woman should have the right to choose how they birth . . . You’re

treated like you have no agency, no right over your body [when pregnant] . . . You should have

the right to say, no, I don’t want a doctor”.

A respondent explained to a friend that she didn’t get a midwife but was still just going to

birth at home, her friend responded, “you can do that?” All women described questions and

issues around principles and philosophies of individual autonomy and agency, power,

knowledge, feminism, and critical thinking in general either during or after their maternity care

experiences.


Issues of identity including as it relates to birth and parenting practices were raised by

interviewees. Being denied midwifery, as well as being unable to breastfeed, were discussed as a

threat to some women’s identities. With reproduction tied to cultural ideas of womanhood in

many ways, any threat to participants’ expectations of what pregnancy, birth, and parenting

should look like may threaten their personal identity. For one participant, being told she was

unable to breastfeed was a significant challenge to how she envisioned herself as a mother.

Amplifying the distress associated with that challenge was the insensitive nature of care

providers who were unwilling or unable to grasp the significant personal struggle that

accompanied that diagnosis. Similarly, for one participant, a homebirth was described as the top

priority for her pregnancy after having a negative first birth experience in a hospital. After being

denied midwifery and by extension, the option to homebirth, this participant spent a period of

time with no care provider just trying to come to terms with what she would do for a care

provider and her birth. All participants described a fundamental belief in their physiological

abilities to birth their children and experienced considerable challenge in dealing with care

providers who did not seem to share or respect that deeply held belief.

Respondents also explained that “birth shouldn’t be feared”. One respondent expressed

concern that young women in particular (in the context of sexual education in formal educational

settings) need to have access to more and better knowledge about pregnancy and birth, including

understanding emotional and physical markers of stages of labour and how to work with

contractions. The considerations participants expressed about these larger scale social issues

point to a desire to see change in the cultural understandings surrounding childbirth.

Initial lack of knowledge


Multiple women described a lack of understanding about how midwifery care worked in

the health care system including being unsure if they needed a referral, and how to begin

accessing it, as well as being unaware of how early in pregnancy they needed to contact

midwives in order to become clients. This occurrence connects to the concerns with the health

care system and inequalities within it as discussed above. If women are unaware of the options

available to them, or of how to procure those options, this presents significant barriers in what is

allegedly a universally available public service. One respondent described, as a first-time mother,

not knowing how she would tolerate birth and wanting to be in a hospital to have access to

specialized care if needed. After having a hospital birth experience she explained that the desire

to birth in hospital was a decision made with incomplete information and not the location she

would opt to birth in if given the choice again. The notion that doctors ‘know best’ was also

raised multiple times, with women sometimes submitting to the pressure of doctors based on

their positions of authority and knowledge.

A lack of knowledge and/or experience was also connected to a lack of confidence. As a

first time mother, one respondent stated that she, “definitely wasn’t confident enough to fire

doctors at the last minute”.

Birth and social relations

Respondents discussed their social interactions with other individuals and other mothers.

One respondent explained, “other moms ask “why complain? You didn’t have a c-section” and

there was a lot of “I wish I had your hospital experience!” and I had to bite my tongue”.

Another respondent explained, “there are other moms saying ‘those interventions you

don’t want save lives you know!’”. It was obvious that there were multiple examples of women


being unable to openly express their own disappointments or frustrations with their own births

among many of their peers and experiencing significant push-back from peers when they did,

either because peers thought their own experiences were comparatively worse, or because peers

did not see the issue that the participants had with the care they had received.

Willing to accept needed care

Women interviewed repeatedly stated that they would accept interventions if they were

needed. One woman stated, “I would accept interventions if I needed them, I’m not an idiot.

What I object to is being given the intervention before it’s needed”. The pressure to accept

interventions imposed by doctors and nurses was resisted when women felt those interventions

were not truly necessary, but women were very clear that they were not opposed to the notion of

interventions in some instances.

Recommendations

In the course of the interviews, women provided a number of recommendations based on

their experiences including

Better training for nurses in particular and health care workers in general. Since

nurses are the providers who women often interact with most in hospitals, it was

particularly emphasized for that group. Specific suggestions included Bradley

methods (a child birth class), natural childbirth classes of some kind, doula

training, and non-violent communication training. Another suggestion pointed to

training and/or literature on the motivations of women who choose midwifery

care to better prepare care providers in supporting these women.


Equipping physicians with more (and up-to-date, evidence-based) breastfeeding

knowledge, so they might better support women (or at least discourage them from

providing women with inaccurate, out-dated information).

The creation of a hierarchy structure of maternity care, in which, low-risk women

are seen by midwives, general practitioners would attend women with needs

beyond the scope of midwives, and obstetricians would be reserved for high-risk

women. This would ensure low-risk women were not unnecessarily subjected to

high-risk care.

Women suggested better practices for midwives to communicate their inability to

take on potential clients to those individuals. Many women did not receive any

communication back from a number of midwifery practices despite multiple

attempts to communicate. One respondent suggested an automated email or

voicemail message to keep women better informed. She stated, “I felt like re-

applying and re-applying just to get that closure”.

More education for women regarding the normal physiological process of labour.

Women would like to see the creation of a group of general practitioners that truly

practice similarly to midwives in terms of the philosophy of care and relationships

had with clients. “If there are no midwives available then you need to know where

to go to get that same respect. Nobody has a website that says ‘we’re natural-

birth friendly’”.

One very inherent recommendation which was not as often explicitly stated, was that

women ought to have access to midwives. Being able to make choices in pregnancy and birth,


and choices about the type of maternity care women attain was described as “something every

women should have a right to”.

Future Plans

All women described their intention to try for a midwife again in any future pregnancies

and some described a desire to avoid a physician again in the future. One woman described her

continued preference for a midwife, but the choice not to utilize a TBA again in the future

because of “too many unknowns”. Another respondent stated that if she could not get a midwife

she would seriously research the possibility of birthing unassisted at home. One respondent also

expressed a desire to move elsewhere before having more children, to a community better

serviced by midwives, or for the maternity health care system to have improved before she

expects any future children.

Discussion

The World Health Organization (WHO), states that “health systems must be accountable

for the treatment of women during childbirth, ensuring clear policies on rights and ethical

standards are developed and implemented. Health-care providers at all levels require support and

training to ensure that childbearing women are treated with compassion and dignity” (2014). The

issue of dignity and respect in childbirth is not only an issue in lesser developed nations, and the

WHO is presently gathering data on women in childbirth in facilities across the globe in order to

inform research and aid in developing tools to measure incidents of disrespect and abuse in

childbirth (ibid), the likes of which was discussed frequently in interviews here. The question of

the Alberta health care system’s accountability in the treatment of women who want, but cannot

access midwifery care is also raised here, when it is clear that only some women can access this

type of care.


The data presented in this research project supports the need for the ongoing work of the

WHO and the need in general to work to improve reproductive experiences for women in

Alberta and more generally in Canada. The WHO points to the health care system as an

organization which must be accountable for the treatment of women. Unfortunately, the

circumstance for women who are unable to access midwifery care is created by the health care

system itself and its’ inability to meet consumer needs. The demand for midwifery is great, and

yet the health care system is not appropriately funding and supporting this model of care. Instead

of a de facto maternity care lottery which sees luck as the factor deciding who receives

midwifery care and who does not, leaving the latter group of women no choice but to see a

physician or birth unattended, the province need to revise its approach to funding to ensure that

consumers can access whichever maternity care model is more appropriate for them. Truly

providing access requires sufficient financial and structural support. Until that change happens,

the health care system maintains systemic inequalities resulting in women receiving different

types of maternity care.

The data presented here points to incredible complexity. Birth is not a subject easily

analyzed or readily understood in its entirety. As mentioned at the outset of this paper, the

concept of birth is intimately tied to many far-reaching issues and topics including broad scope

issues such as human rights, social justice, politics, as well as micro-level topics including

interpersonal interactions and personal beliefs. Any research attempting to understand birth, how

it is experienced, and how to rectify injustices done to women in connection to lack of choice in

care for childbirth will have to approach the subject with this complexity in mind. The

motivations described above by women wanting midwifery, that is, to achieve intervention-free

birth experiences, respect, agency, and a relaxed, low-key tone, are significant. Also significant


is the fact that women do not seem to feel confident that their priorities could be met in a

physician-led birth. These priorities are not the outlandish demands of fringe-residing birth

zealots. To be respected, to have the power to act on one’s agency and autonomy, to birth

without unwanted interventions, and to approach care in a calm and relaxed way are priorities

that ought to be incorporated by any maternity care provider. Longstanding midwifery practices

demonstrate that each of these priorities is achievable for birthing women. As the demand for

midwifery grows, it seems entirely likely that the number of women expecting maternity care

that meets these priorities is also only going to grow. While health care system administrators are

developing expansions in their midwifery care, it also seems relevant to wonder whether they

will be looking at significant changes to the culture of childbirth in general, and related changes

in physician-led and hospital-located births that suit the priorities described by women here.

Respect

Many themes have been presented here regarding the experiences of women denied

midwives, ranging from their motivations for midwifery to their post-partum care. In broadly

considering the specific themes presented, the concept of respect appears present as an over-

arching topic. When women seek out intervention-free births, they are arguably seeking out a

birth, which respects and honours what is their knowing and confidence in their bodies’ innate

physiological ability to reproduce. When women want to be accorded respect and use their

power to make choices, they are doing so with the expectation that they are worthy of and able to

receive the respect of others in society. This includes respect from care providers towards

women who act on the agency and autonomy each embodies as a knowing pregnant and birthing

being.


Negative emotions experienced by pregnant women when receiving notice of the denial

of midwifery care are connected to distress and fear of a failure to be respected, not only by the

caregivers they are forced to ‘choose’, but also by a system which denies them the care they

ought to have access to as citizens. Midwifery is well-known for its’ respect of women. When

women are refused that known security, it is not surprising that their emotional reaction is

negative. Poor relations with care providers can easily be explained due to a lack of respect,

whether it be for women as patients or for the maternity care choices they are opting for. Women

in this study worked hard to build and fortify their knowledge in anticipation of the battle to win

respect from their care providers and to be able to stand up to them, in addition to a desire to

make well-researched, evidence-based choices. Pressure and threats from medical staff may be a

response to their own feelings of a lack of respect from pregnant and birthing women when they

refuse to conform to the norms of the maternity care system and in the healthcare environment

where medical staff are traditionally viewed as holding vested authority. Women who reject a

medical model of care are then left with few options and are apt to experience and even create

tensions. Medical staff familiar with being respected based on their medical authority alone may

be unfamiliar and uncomfortable with the resistance that midwifery-minded patients may bring.

With the theme of respect in mind, power struggles and dissatisfaction in birth are also

not surprising as they’ve been described here. Women’s dissatisfaction expressed as feeling they

are at the whim of the policies of a bureaucratic system may be amplified as they navigate that

same health care system which traditionally expects behaviour to be decided by policies and

procedures, rather than individual agency and autonomy even if these are based on research and

evidence. The oft described as abusive care women experience at the hands of hospital staff is

one of the most heavily emphasized issues established in this research project. It is possible that


a lack of respect for women in society places them in a position where abuse is more likely. In a

patriarchal society, women are often already inherently less respected. As vulnerable patients in

an authoritative hospital setting, it is not unlikely that the risk of abuse would grow considerably.

Women in this study have sought out positives in their experiences which, was highlighted by

kind, compassionate, and respectful treatment by some care providers.

Finally, in post-partum care women described processing their experiences, which

included working through rose-coloured perceptions of their experience, and validating negative

emotions, particularly anger at how they were treated. This anger is potentially a very validating

response to the intense disrespect many experienced during their birth. Negative hospital

experiences characterized by unwelcome sleep disturbance and surveillance, and negative health

nurse experiences characterized by threats and surveillance all point to the absence of respect

towards women in labour and childbirth.

Women want to be respected, to make their own choices, to have access to the type of

care they are entitled to as citizens, to exercise their own agency and autonomy and have others

respect that, and to have their bodies respected. This statement is not only relevant to maternity

care, but as a statement applicable to the position of women in North American society today.

Information and (Re-) Education

One of the realities in every interview was the emphasis participants placed on going to

great lengths to educate themselves. All participants researched everything from medical

procedures and outcomes, to their own rights, to how they might want to labour and birth, to

which care provider they would access. The women interviewed were all undeniably

knowledgeable about pregnancy and birth. The research women did was not only for themselves

to base their decisions about care on, but also was utilized as evidence to justify the legitimacy of


their decisions to their care providers. Research was often wielded as a shield and viewed as

providing strength. The process of researching to develop and expand knowledge was also

described as empowering and contributing to personal growth beyond pregnancy and birth

experiences.

Having access to more information on pregnancy and the physiology of birth, and having

access to it earlier in life, were included in the recommendations made by interviewees. Both

formal education (such as sexual education content) and a more general cultural level of

information were pointed to as sources of information, which could and/or should be improved.

It’s possible that if more information about the process of birth were available to women earlier

in life that women in the reproductive phase of life would not be left to spend so much effort

doing individual research. Further, it is also possible that the added information made widely

available would benefit many women who might not otherwise engage in personal research. The

empowerment and confidence women experienced upon becoming more informed about

reproduction is an experience that could be drawn on to improve the reproductive experiences

and outcomes of women in general. For women who have been denied midwives in particular,

some kind of educational support(s) may be one important way to help women out of that chasm,

particularly those who might experience additional barriers (time, access, skill) to carrying out

the significant amounts of research described by the participants here.

Limitations

Women who participated in this research self-identified. As such, this may have impacted

the results. It is possible that women harbouring dissatisfaction are more likely to speak up about

their experiences and share their negative stories. Simultaneously, it is also conceivable that


women with especially traumatic stories may have been so significantly distressed by their

experiences that they do not wish to discuss them.

As this study is a preliminary and solely qualitative exploration into the issue of a lack of

midwifery service in Alberta, no significant attempt has been made to be representative of all of

the local population. The results here are from a small number of respondents in an effort to

explore deeply how being denied the choice of midwifery care has impacted the experiences of

research participants. Recruitment occurred in a relatively small number of spaces across a

limited number of mediums (free local print resources, online and word of mouth, as discussed

above). As the intention of this research was to develop rich detail on the experiences of women

denied midwifery care as there first choice of healthcare, women from other groups (that is,

those whose first choice of care provider were physicians) were not included.

Many of the women in this research described a lack of knowledge surrounding how to

access midwifery and even how midwifery ‘works’. Beyond that is seems quite likely that, in the

absence of public advertising to inform women of the midwifery option, there are women who

still are unaware of midwifery as a publicly funded option, theoretically available to them. It has

also been suggested that primary care physicians, who may often be the first-stop for women

who believe they are pregnant, may also be insufficiently knowledgeable about midwifery to

support women in knowing their options and making an informed choice on their own maternity

care. The potential knowledge gap, both in primary care and in general public knowledge, in the

range of choices for women is another form of denial and inequality that this research does not

address. Further investigation is recommended to bring the larger context into focus.


Concluding Thoughts

As discussed above, many women who participated in this study provided valuable

recommendations for change in their interviews based on their experiences. As the individuals

located on the front consumer line of maternity care, these recommendations carry significant

weight. Most obviously, these women believe that they should have access to midwifery

maternity care. Whether improved access to midwives means more funding, a different funding

model, and increasing the midwifery workforce, women very clearly indicated that providing

better consumer access to midwives ought to be a major priority. In participants’ maternity care

experiences without midwives, the importance of health care providers, specifically nurses in

hospital settings, was emphasized based on their ability to negatively or positively impact a

maternity experience. Many respondents recommended additional training for health workers on

topics such as natural child birth classes and doula training to enable them to better support

women in intervention-free births, as well as non-violent communication to improve the

interactions they would have with patients. It was also recommended that health care workers be

exposed to training or information that would help them to appreciate and understand the

perspectives and motivations of women who seek out midwifery care, and how they might help

bridge the gaps that exist between contemporary medical and midwifery care. Based on the data

and analysis presented here, this approach seems like one of the most appropriate possibilities to

address multiple issues that women described in their reproductive experiences. If applied across

the health care worker spectrum to include doctors, hospital-based nurses, and public health

nurses, all providers that women interact with would be given the opportunity to become better

prepared to support the women they provide services to.

More education opportunities for women that include information about midwifery care,

as part of public health services is another recommendation made by participants, which seems


particularly relevant and significant. More women with more information are more able to drive

positive change for all women from within and outside of the health care and political systems.

The women in this research advocated for themselves based on their knowledge. As more

women become knowledgeable about their options and begin to advocate for them, the health

care system, health care culture, and culture in general are more likely to shift.

This research is a preliminary exploration into the experience of women denied

midwifery because of a lack of sufficiently available care. As most of the women interviewed

settled on physician-led care, this work may point towards issues to address in facility-based,

physician-attended maternity care as well. From here, a broad, representative project would do

well to establish the concerns of pregnant and birthing women on a larger scale and begin to take

action to address concerns. It is likely that actions to create change would be most effective if

applied with the support and assistance of provincial health care authorities and regulatory

bodies.

This research has created detailed themes that exist in the various phases of maternity

care as described by women denied midwifery care in Edmonton. Research participants’ first

choice for pregnancy and childbirth care was midwifery care. Participants made this choice

informed by their own research and knowledge of the midwifery model of care, which

deliberately includes respect for women’s autonomy and choice. The loss of choice and respect

for these women when they are denied the care of a midwife throughout their pregnancy and

childbirth is a major theme throughout the interviews

The very real struggle of women who are denied midwifery care continues and is far too

common. The number of volunteers for this study far outweighed the available research space,

and the interest and support for the project were even more far-reaching. The data presented here


points to the reality that being denied the choice of a midwife matters. With the rate of growth of

demand for midwifery appearing to be as rapid as it is, it seems unlikely that the system will be

able to change sufficiently and quickly enough to meet the demand anytime in the very near

future. For the time being, too many women in Alberta endure prenatal care, births, and post-

partum care with the same injustices as described by the women interviewed in this work.

Anecdotally, stories like those shared by the women here are not uncommon. Choice in how one

births matters. Bodies like the World Health Organization have recognized the importance of

compassionate, respectful, and dignified maternity care (2014). Even aside from these official

endorsements, it seems painfully obvious that a woman ought to have the right to choose how to

birth and to have that choice respected.

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