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The impact of a difficult birth on mothering over time Rollison, Lynn 2015

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  THE IMPACT OF A DIFFICULT BIRTH ON MOTHERING OVER TIME by Lynn Rollison  Bachelor of Science in Nursing, University of Victoria, 1990 Master of Arts, University of Victoria, 1996   A THESIS SUBMITTED IN PARTIAL FULFULLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  DOCTOR OF PHILOSOPHY in THE COLLEGE OF GRADUATE STUDIES  Interdisciplinary Studies  THE UNIVERSITY OF BRITISH COLUMBIA (Okanagan) December 2015   © Lynn Rollison, 2015   ii  Abstract  Existing literature about childbirth does not clearly address the relationship between women’s experiences of “difficult birth” and the meanings women create from those events. This research focuses on women who identified they experienced a difficult birth, as opposed to a traumatic birth a topic that has received some attention. The experiences of 12 women and how a difficult birth affects the mother and how she creates meaning about it over time were explored. I focus on the women’s perceptions about their ability to mother and on the relationship between the infant and the family. The women’s stories are analyzed through ethnographic-informed methods with a feminist perspective. The absence of information about women’s experience of difficult birthing and their subsequent mothering is due to the silencing of their voice and a lack of investigation into their concerns during childbirth. This research identifies six themes common to the women’s stories: health care professionals who have the dominant or authorial voice; hospital staff, who share little or no information with the women about their care; women, who are made to feel inadequate by HCPs; women, who experience an absence or a lack of care or assessment; significant others who abandon the women; and, women who experience ethical situations concerning their own care and that of their infant. I conclude that mothering over time is deeply affected by the experience of difficult birth, despite the varied and diverse situations and the contexts of difficult births.      iii  Preface This dissertation is original, unpublished, independent work by the author, Lynn Rollison. The University of British Columbia, Okanagan Ethics Board approval for the project, the impact of a difficult birth on mothering over time, ethics number H11-00679.       iv  Table of Contents ABSTRACT .............................................................................................................................................................  II PREFACE ..............................................................................................................................................................  III TABLE OF CONTENTS ............................................................................................................................................ IV LIST OF TABLES ..................................................................................................................................................  XIII LIST OF ILLUSTRATIONS ...................................................................................................................................... XIV ACKNOWLEDGEMENTS ........................................................................................................................................ XV DEDICATION ....................................................................................................................................................... XVI CHAPTER 1 INTRODUCTION ..................................................................................................................................  1 PERSONAL PERSPECTIVE AS A NURSE ................................................................................................................................  3 POSITIONING THE SELF ...................................................................................................................................................  4 UNFOLDING THE NARRATIVES..........................................................................................................................................  5 SIGNIFICANCE OF THE STUDY ...........................................................................................................................................  6 CONTRIBUTIONS TO KNOWLEDGE .....................................................................................................................................  7 CHAPTER 2 POSITIONING THE STUDY ...................................................................................................................  9 PREGNANCY AND BECOMING A MOTHER: A SOCIO-CULTURAL PERSPECTIVE ..........................................................................  10 QUALITIES OF A SATISFACTORY BIRTH EXPERIENCE ............................................................................................................  14 ATTACHMENT THEORY .................................................................................................................................................  17 MEDICAL CONTROL OF CHILDBEARING: CAESAREAN BIRTHS ................................................................................................  19 Operative Births in British Columbia (B.C.) ........................................................................................................ 21 UNSATISFACTORY BIRTH EXPERIENCES ............................................................................................................................  23 WOMEN’S BIRTHING EXPERIENCE: TRAUMA AND POST-TRAUMATIC STRESS DISORDER ............................................................  26 STRUCTURAL VIOLENCE ................................................................................................................................................  28 BABY AS PRODUCT ......................................................................................................................................................  29 WOMEN, MOTHERING AND BEING FEMALE .....................................................................................................................  30    v  SURVEILLANCE: MEDICAL GAZE OF THE FEMALE BODY .......................................................................................................  31 A WOMAN’S DESIRE FOR BIRTH ....................................................................................................................................  36 Choice ................................................................................................................................................................ 36 Corporeality ....................................................................................................................................................... 37 CHAPTER 3 THEORY AND METHODS ...................................................................................................................  40 FEMINIST EPISTEMOLOGY .............................................................................................................................................  41 FEMINIST RESEARCH ....................................................................................................................................................  42 KEY HALLMARKS OF FEMINIST METHODOLOGY .................................................................................................................  44 Voice .................................................................................................................................................................. 44 Ethics ................................................................................................................................................................. 46 Reflexivity and Transformation ......................................................................................................................... 47 Meaning Making ............................................................................................................................................... 50 ETHNOGRAPHY ...........................................................................................................................................................  52 CRITICAL ETHNOGRAPHY ..............................................................................................................................................  54 METHODS .................................................................................................................................................................  55 AIMS OF THE RESEARCH ...............................................................................................................................................  56 ARTIFACTS .................................................................................................................................................................  57 ETHNOGRAPHY: LIFE HISTORY THROUGH STORIES OR NARRATIVES .......................................................................................  58 LIFE HISTORY: HEARING WOMEN’S STORIES THROUGH THICK DESCRIPTION ...........................................................................  58 RECRUITMENT AND WORKING WITH PARTICIPANTS ...........................................................................................................  59 Initial Contact with Participating Women ......................................................................................................... 59 The Twelve Women ........................................................................................................................................... 61 DATA COLLECTION ......................................................................................................................................................  63 METHODS OF DATA ANALYSIS .......................................................................................................................................  64 RIGOUR ....................................................................................................................................................................  65 CHAPTER 4 WOMEN’S STORIES OF CHILDBIRTH ..................................................................................................  68    vi  AMBER: NARRATIVE OF DIFFICULT BIRTH.........................................................................................................................  69 Impact of a Difficult Birth on Mothering ........................................................................................................... 70 BARBARA: NARRATIVE OF DIFFICULT BIRTH ......................................................................................................................  71 Impact of a Difficult Birth on Mothering ........................................................................................................... 73 CAROL: NARRATIVE OF DIFFICULT BIRTH .........................................................................................................................  73 Impact of a Difficult Birth on Mothering ........................................................................................................... 74 DIANA: NARRATIVE OF DIFFICULT BIRTH ..........................................................................................................................  75 Impact of a Difficult Birth on Mothering ........................................................................................................... 76 EILEEN: NARRATIVE OF DIFFICULT BIRTH .........................................................................................................................  77 Impact of a Difficult Birth on Mothering ........................................................................................................... 78 FRANCIS: NARRATIVE OF DIFFICULT BIRTH .......................................................................................................................  79 Impact of a Difficult Birth on Mothering ........................................................................................................... 81 GILLIAN: NARRATIVE OF DIFFICULT BIRTH ........................................................................................................................  81 Impact of a Difficult Birth on Mothering ........................................................................................................... 83 HILLARY: NARRATIVE OF DIFFICULT BIRTH........................................................................................................................  84 Impact of a Difficult Birth on Mothering ........................................................................................................... 85 ISABELLE: NARRATIVE OF DIFFICULT BIRTH .......................................................................................................................  86 Impact of a Difficult Birth on Mothering ........................................................................................................... 87 JENNIFER: NARRATIVE OF DIFFICULT BIRTH ......................................................................................................................  88 Impact of a Difficult Birth on Mothering ........................................................................................................... 90 KAREN: NARRATIVE OF DIFFICULT BIRTH .........................................................................................................................  91 Impact of a Difficult Birth on Mothering ........................................................................................................... 92 LYANNE: NARRATIVE OF DIFFICULT BIRTH ........................................................................................................................  93 Impact of a Difficult Birth on Mothering ........................................................................................................... 94 CHAPTER 5 EMBODIED PREGNANCY AND PRETERM BIRTHS ...............................................................................  97 STRUCTURED SURVEILLANCE .........................................................................................................................................  98    vii  Structured Surveillance Through Antenatal Education ................................................................................... 100 NON-ATTENDANCE AND ATTENDANCE TO PRENATAL EDUCATION ......................................................................................  103 PUBLIC PREGNANT BODIES AND THE LIVED EXPERIENCE OF PRETERM BIRTH .........................................................................  107 ILLNESS AND SUFFERING: CONFOUNDING ACTS OF CARE ..................................................................................................  111 MANAGING UNPREDICTABILITY: CONTROLLING THE CORPOREAL ........................................................................................  113 Shrouded Suffering: Unrelenting PPD ............................................................................................................. 116 Stigma and Medicalized Birth: Normalizing PPD ............................................................................................ 118 Failure of the Corporeal: PPD and Thoughts of Suicide ................................................................................... 121 OVERWHELMING CIRCUMSTANCES: PREMATURITY, FRAGILITY AND THE THREAT OF LOSS........................................................  122 Re-Igniting PTSD: Embodying New Injuries ..................................................................................................... 123 Overwhelming Stressors and Coping with Preterm Birth ................................................................................ 124 Breast Milk and the Premature Infant ............................................................................................................ 125 Postpartum Depression, PTSD and Hospitalization ......................................................................................... 126 CHAPTER 6 FAILING BODIES, STIGMATIZED EMBODIMENT AND  BIRTHING WOMEN’S STRUGGLES .................  130 THE BIOMEDICAL MODEL OF CHILDBIRTH: WHOSE INTERESTS DO THEY SERVE? ...................................................................  130 GILLIAN AND DIANA ..................................................................................................................................................  131 Stigma: Ignored Suffering ............................................................................................................................... 134 Unethical Actions: Systemic Patriarchy ........................................................................................................... 136 DIANA: STIGMA AND FORCED LABOUR ..........................................................................................................................  137 AMBER: BIRTH FROM THE MARGINS .............................................................................................................................  141 Body Scarring .................................................................................................................................................. 143 Scarring: Medicalized Births and Untold Risks for the Mother and Baby ........................................................ 145 Tears and the Object Body of the Corporeal Self ............................................................................................. 146 Psychic or Emotional Scarring ......................................................................................................................... 147 EILEEN ....................................................................................................................................................................  148 Scarring: Failure to Acknowledge the Corporeal Experience ........................................................................... 149    viii  Scarring: Marginalized Subjectivity ................................................................................................................. 151 Scarring: Recuperation from Medicalized Care ............................................................................................... 152 CHAPTER 7 LOSS AND UNETHICAL TREATMENT AND POST-TERM BIRTH ..........................................................  155 JENNIFER .................................................................................................................................................................  155 Crumbling Expectations: The Myths that Erode Reality .................................................................................. 156 Undermining Confidence: PPD ........................................................................................................................ 157 Crumbling Expectations: Cancer, Suffering and Death ................................................................................... 158 Crumbled Future: Living with Loss................................................................................................................... 160 Living with Loss: Moving Forward ................................................................................................................... 163 No Words for Loss ........................................................................................................................................... 165 KAREN ....................................................................................................................................................................  166 Social Construction of Induction: Experimentation on the Corporeal Body .................................................... 167 Experimental Approaches: Newborn in Jeopardy ........................................................................................... 168 Recognizing the Hegemony ............................................................................................................................. 170 FRANCIS ..................................................................................................................................................................  171 Multiple Understandings of Post Term Pregnancy .......................................................................................... 173 Normalized Medical Practices of Corporeality ................................................................................................ 173 Embodied Experience of Induction of Labour .................................................................................................. 175 “I’m in Trouble”: Extensive Second Stage of Labour ....................................................................................... 176 Help Arrives: Loss of Hope for “Normal Birth” ................................................................................................ 178 Failed Body: Disappointment, Suffering and Shame ....................................................................................... 181 Recovering Through Embodied Grief and Sorrow ........................................................................................... 183 Recreating Birth: Attempts to Heal the Pain ................................................................................................... 184 Not Being Attended to and the Creation of a “Sad Mother” ........................................................................... 185 CHAPTER 8 BEING ALONE AND THE SHAPING OF RELATIONSHIPS ....................................................................  188 SUPPORT DURING LABOUR AND BIRTH ..........................................................................................................................  188    ix  BEARING WITNESS ....................................................................................................................................................  189 ALONE IN LABOUR ....................................................................................................................................................  190 OVERWHELMING ABANDONMENT: BARBARA’S STORY .....................................................................................................  190 The Medical Model and Violations of Dignity ................................................................................................. 193 Standing her Ground and Pushing Others Away ............................................................................................. 194 Lack of Presence and Calming Touch .............................................................................................................. 196 Shifting and Unstable Ground ......................................................................................................................... 197 PREMATURITY, ILLNESS AND FACING SUFFERING ALONE ...................................................................................................  199 Shaping Understanding and Not Relying on Others ........................................................................................ 200 APPENDICITIS, PRETERM LABOUR AND SUFFERING ALONE ................................................................................................  201 PREGNANCY AT RISK, UNCERTAIN RELATIONSHIPS AND ABANDONMENT ..............................................................................  202 CHAPTER 9 CONSTRUCTED UNDERSTANDINGS:  GUILT, LOVE, VULNERABILITIES AND MOTHERING ………………  206 VULNERABLE POSITION: I SHOULDN’T FEEL GUILTY .........................................................................................................  207 MANY LEVELS OF GUILT .............................................................................................................................................  208 STRUCTURED OPPRESSION AND FEELINGS OF GUILT .........................................................................................................  209 MEDICAL BIRTHING AND MULTIPLE GUILT: THE STRUCTURING OF CHILDBEARING ..................................................................  210 INSTITUTIONAL AGENDAS AND MULTIPLE GUILT .............................................................................................................  211 IN THE PAST: WORKING THROUGH GUILT ......................................................................................................................  211 THE GUILT BOX ........................................................................................................................................................  213 ONGOING WORK: GUILT AND GRIEF.............................................................................................................................  214 GUILT: PPD, PTSD AND BREASTFEEDING ......................................................................................................................  215 TRANSITION TO MOTHERHOOD AND LOVE .....................................................................................................................  216 WHEN LOVE BEGAN ..................................................................................................................................................  216 Love Right at the Start..................................................................................................................................... 217 Love after Recovery ......................................................................................................................................... 217 Love before Pregnancy .................................................................................................................................... 218    x  Mother’s Love for a Third Child ....................................................................................................................... 218 Love: Words are Not Enough........................................................................................................................... 219 Remarkable Occurrence and Early Love .......................................................................................................... 220 Desperate for a Baby ....................................................................................................................................... 220 ASPECTS OF DIFFICULT BIRTHING AND RESULTANT VULNERABILITY .....................................................................................  220 Amber Speaks of Vulnerability ........................................................................................................................ 221 Barbara Speaks of Vulnerability ...................................................................................................................... 223 Diana Speaks of Vulnerability ......................................................................................................................... 225 Francis Speaks of Vulnerability ........................................................................................................................ 227 Isabelle Speaks of Vulnerability ....................................................................................................................... 228 Lyanne Speaks of Vulnerability........................................................................................................................ 230 TAKING THE EXPERIENCE OF DIFFICULT BIRTHING INTO MOTHERING ...................................................................................  231 “I Didn’t Have Control like I Thought I Should” ............................................................................................... 232 Healing: Legacy of Abandonment ................................................................................................................... 232 “I’m Their Rock” .............................................................................................................................................. 233 “It’s a Cycle” .................................................................................................................................................... 234 “Close Connections” ........................................................................................................................................ 234 “Pushing and Pulling and Tugging” ................................................................................................................. 235 “War Stories” .................................................................................................................................................. 236 “It’s Always Part of Me” .................................................................................................................................. 237 “You Live Around the Scars” ............................................................................................................................ 237 Seeing the “Big Picture in Life” ........................................................................................................................ 238 Fragility and Fear of Loss ................................................................................................................................ 239 Hypervigilance and Bonds ............................................................................................................................... 239 THEMES FROM THE WOMEN’S EXPERIENCES ..................................................................................................................  240 REFLECTIONS AS A WOMAN, NURSE AND RESEARCHER ....................................................................................................  241    xi  CHAPTER 10 DIFFICULT BIRTHING AND SURVEILLANCE .....................................................................................  244 SURVEILLANCE ..........................................................................................................................................................  244 THE AUTHORIAL VOICE ..............................................................................................................................................  245 ENFORCED SILENCE: FAILURE TO INFORM OR INCLUDE WOMEN .........................................................................................  246 Complicity of Silence by Nursing: Doing Harm ................................................................................................ 248 Silence or Stifled Responses: Prematurity ....................................................................................................... 250 Women’s Silence ............................................................................................................................................. 251 Authorial Voice and Silence: Withholding Information as an Act of Control................................................... 253 Authorial Voice and Silence: Acts of Punishment ............................................................................................ 254 Kept in the Dark: Silence through Omission .................................................................................................... 255 AUTHORIAL VOICE: BULLYING AND “MADE TO FEEL STUPID?” ..........................................................................................  257 BULLIED INTO SUBMISSION: IGNORED AND NEGLECTED ....................................................................................................  259 Visibility ........................................................................................................................................................... 261 ISOLATION: BEING ABANDONED ..................................................................................................................................  262 PROJECTED STIGMA AND ETHICAL ISSUES: DISRESPECT, BIAS AND DISCRIMINATION ...............................................................  264 ETHICAL ISSUES: CHILDBEARING WOMEN NOT AT THE CENTRE OF CARE ..............................................................................  265 PARTICIPANTS’ RESPONSES TO HCPS ............................................................................................................................  267 SURVEILLANCE AND THE CONSTRUCTION OF MEDICALIZED CARE ........................................................................................  270 CHAPTER 11 SUMMARY: REFLECTIONS AND REFLEXIVITY .................................................................................  272 LIVING THE EPISTEMOLOGY AND METHODOLOGY ............................................................................................................  274 Voice ................................................................................................................................................................ 275 Ethical Concerns: Experiences of Women........................................................................................................ 276 Reflexivity and Transformation ....................................................................................................................... 277 REFLEXIVITY AND WOMEN’S KNOWLEDGE .....................................................................................................................  278 MY OWN REFLEXIVITY ...............................................................................................................................................  279 BEYOND THE MARGINS ..............................................................................................................................................  280    xii  STUDY RECOMMENDATIONS FROM PARTICIPANTS ..........................................................................................................  281 RECOMMENDATIONS .................................................................................................................................................  282 LEARNING FROM MOTHERS ........................................................................................................................................  285 INFLUENCE ON KNOWLEDGE AND RESEARCH CONTRIBUTIONS ...........................................................................................  287 AREAS FOR FUTURE STUDY .........................................................................................................................................  287 END NOTE ...............................................................................................................................................................  288 REFERENCES ......................................................................................................................................................  289 APPENDICES......................................................................................................................................................  347 APPENDIX A: GLOSSARY .............................................................................................................................................  347 APPENDIX B: CONSENT FORM FOR ARTIFACTS ................................................................................................................  353 APPENDIX C: STARTER QUESTIONS FOR INTERVIEWS WITH WOMEN ...................................................................................  359 APPENDIX D: ADVERTISEMENT FOR PARTICIPANTS ..........................................................................................................  360 APPENDIX E: CONSENT FORM .....................................................................................................................................  361 APPENDIX F: LETTER TO PARTICIPANTS ..........................................................................................................................  364 APPENDIX G: LIST OF PACKAGE ENCLOSURES .................................................................................................................  365 APPENDIX H: CONFIDENTIALITY AGREEMENT .................................................................................................................  366 APPENDIX I: CONTACT INFORMATION ...........................................................................................................................  368 APPENDIX J: POSTER .................................................................................................................................................  369 APPENDIX K: COUNSELLING SERVICES ...........................................................................................................................  370 APPENDIX L: CURRENT PRACTICES AND USING THE RESEARCH KNOWLEDGE .........................................................................  377     xiii  List of Tables TABLE 3.1 WOMEN’S BIRTH DEMOGRAPHICS .......................................................................................................................  62    xiv  List of Illustrations ILLUSTRATION 5.1 HILLARY’S DAUGHTER’S HAT AND TEDDY BEAR……………………………………………………………………………………….   111 ILLUSTRATION 5.2 CAROL’S FINGERPRINTS AND HER INFANT’S FOOTPRINTS ...............................................................................  112 ILLUSTRATION 5.3: PHOTOS OF ISABELLE’S SON IN THE INCUBATOR AND A PRETERM DIAPER .........................................................  116 ILLUSTRATION 5.4: PHOTOS OF THE CRADLE THAT WRAPPED AROUND LARA WHEN IN THE INCUBATOR ...........................................  127 ILLUSTRATION 6.1: GILLIAN WITH HER THREE CHILDREN ........................................................................................................  137 ILLUSTRATION 6.2: AMBER’S DAUGHTER BEING ASSESSED AFTER BIRTH ....................................................................................  144 ILLUSTRATION 6.3: EILEEN’S DAUGHTER’S FAVOURITE BUNNY RABBIT ......................................................................................  154 ILLUSTRATION 7.1: JENNIFER HOLDS THE ASHES OF HER DAUGHTER HOUSED IN THE TEDDY BEAR ...................................................  160 ILLUSTRATION 7.2: QUILT MADE BY JENNIFER’S MOTHER WITH JADE’S CLOTHING ......................................................................  166 ILLUSTRATION 7.3: THE LOCKS OF KAREN’S CHILD’S HAIR, IDENTIFICATION BANDS AND FOOT MOULD .............................................  170 ILLUSTRATION 7.4: FRANCIS’S SON AT BIRTH .......................................................................................................................  180 ILLUSTRATION 8.1: BARBARA HOLDING A PICTURE FROM THE FIRST WEEK OF HER DAUGHTER’S LIFE ...............................................  197 ILLUSTRATION 9.1: DIANA’S SON AND HER BROTHER. ...........................................................................................................  210     xv  Acknowledgements I could not have embarked on this journey without the stories bravely shared with me by the women participants. I have been profoundly touched by each of your stories and am privileged to have heard your experiences of difficult birth. This work gives evidence of women’s birthing to inform and to make suggestions and changes for the future. Special thanks must be offered to Dr. Penelope Cash for her brilliance, insight, unfaltering faith and direction throughout this work and all of my studies. I have learned to trust and follow your guidance and knowledge of philosophy and appreciate your ability to think deeply. I cannot thank you enough except to pay it forward. I would like to thank Dr. Naomi McPherson for her diligent, thoughtful feedback and her encouragement in a novel approach to the research on motherhood and childbearing that stems from her knowledge and experience in anthropology and study of women globally. To my mother, who showed me how to mother in her everyday actions as she mothered her own children and for loving mine. To my husband, Gordon Cote, you have stood by me through this journey of learning. I am forever grateful for your encouragement and faith in me.    xvi  Dedication This work is dedicated to my Mother and Father who exemplify love, kindness, and understanding.     1      Chapter 1 Introduction Giving birth shapes a woman’s experience of mothering. The act of childbirth is formative and transformative for the woman. Yet, how the birth occurs and what happens during this process is unpredictable and unique for each woman and for each pregnancy she experiences. Despite preparations women may experience birth as a difficult event. I have often heard women describe their births as “difficult” highlighting an under recognized and perhaps traumatic event. Women have identified that being listened to, respected and feeling cared for by family and professionals empowers them and makes their experience positive and rewarding (Hodnett 2002; Howarth et al. 2011; Lavender et al. 1999; Michels et al. 2013). Negative birth experiences have also been studied (Nystedt et al. 2008; Razurel et al. 2011) finding that women who experience traumatic births can develop postpartum depression (PPD) (Beck et al. 2011a; Kinsella and Monk 2009) and posttraumatic stress disorder (PTSD) (Ayers 2007; Beck et al. 2011b; Menage 1993) due to medical interventions (Gamble and Creedy 2004) and the fear of death for herself or her child (Elmir et al. 2012; Souza et al. 2009; Wilde and Murray 2009).  Simkin (1991, 1992b) explored the impact that birthing has on a woman’s life for decades and that women recalled memories of their birth experience with accuracy; indeed many were “strikingly vivid” (1992b:64). For women who expressed overall dissatisfaction with their births, memories of pain, not being listened to and being disregarded all played an important role many years after the event (Waldenstrom et al. 2004a). Forssen (2012) completed a study of older women’s experiences of childbearing and birthing and the significance of those experiences for women’s well-being over their lifetime. Forssen found that during prenatal and maternity care women’s treatment through encounters with health care professionals “are experienced as violations of dignity and abuse, and pose lifelong threats to their health and well-    2      being” (1543). However, despite these studies, there is little research on the impact of a “difficult birth” on women over the long term, the meanings women make of their experiences (Mollard 2014) and the long term effects of the experience on their mothering. Little statistical data is available on the concept of a difficult birth and when it is investigated these studies usually refer to birth “trauma” (Ayers et al. 2006). Birth trauma has been defined as the experience of post traumatic stress disorder that occurs after child birth (The Birth Trauma Association 2015). This research addresses a large gap in the literature in which a difficult birth—when this term is used by women to describe their births—helps to form a particular landscape in women’s experience of childrearing. Furthermore, this issue of difficult births and it’s outcomes for women has concerned me for many years in my practice as an obstetrical nurse.  Informed by feminist and ethnographic methods, my analysis of the narratives of twelve women’s experiences of a difficult birth look more closely at the meaning this event had on their mothering over their life. The significance of this study lies in what is illuminated from the women’s experiences and how their stories of difficult birth and perceptions of their mothering over time have affected them. While I acknowledge circumstances when medical interventions can save the lives of women and their children, my theoretical perspective necessarily requires a critique of the actions and practices of medical practitioners as they impact on women during childbearing.   It is my intention that this research and analysis will have implications for practice, education and policy development in maternal health. Furthermore, this study may also facilitate women’s access to information about possible choices and courses of action in order to avoid the complications of a difficult birth and provide support for women and their families in instances when a difficult birth occurs. Finally the participating women’s experiences and the impact of     3      their difficult births can inform midwives, doulas, doctors or other health care professionals (HCPs) who work with mothers, children and families (Brand and Brennan 2009; Edoka et al. 2011). The study contributes to understandings of women’s experiences during childbirth and how their lives are shaped by this event.  Personal Perspective as a Nurse As a maternity nurse, educator and a mother, I have been amazed by the women who have shared their birth stories with me. Many talked with me about the disappointment they experienced around the process of giving birth. Whether their own expectations are grounded in the cultural construction of pregnancy and birthing or from the fairy tales women are often told about birth, their preconceptions were not met, setting them up for disappointment. My personal experiences and their stories piqued my interest and led me to investigate difficult birthing and the impact it has on mothering. I was particularly curious about how women understand and make meaning from difficult birth experiences over time (Callister 2004). The medical and scholarly term for a “difficult” birth may in fact be a “traumatic” birth but women do not tend to use this term (Ayers 2004, 2007; Beck et al. 2011a; Beck et al. 2011b; Gamble et al. 2005; Modarres et al. 2012). However, in conversations women often referred to these births as “difficult,” perhaps to minimize the effect this might have on the child, to create some distance from the experience, to down play the event or to deny the experience to minimize the trauma. Indeed births defined as traumatic have been recognized and studied in the literature by health professionals and the women experiencing those births were treated in the postpartum period for depression or other conditions. In my nursing practice, time and time again, I heard women use the term “difficult” when describing their birth experience which left me wondering about the aftermath of that event. For this study, it is the women who described their birth as difficult that     4      are of interest. In particular, I wanted to understand how the experience of a difficult birth affects a woman and her mothering and what judgements about mothering and motherhood the women make about their experience of birth. Throughout this study, motherhood and mothering are described by participating women themselves.   My own difficult birthing experience, as a mother, an obstetric nurse and researcher in this study, situates me within the research and provides the impetus for this work.   Positioning the Self I became pregnant during my nursing education. In anticipation of the birth, I attended Lamaze preparation classes in addition to prenatal education. I felt well prepared to give birth. Three weeks prior to my due date, my membranes ruptured spontaneously; yet, labour did not commence. I was admitted to the hospital in the early morning to be assessed for evidence of a prolapsed umbilical cord. Later that morning my contractions began and I experienced back labour, a dysfunctional labour pattern that is often protracted. I received analgesia and some nursing support and was left alone for times during labour. After twenty-two hours, I was fully dilated. The foetus remained posterior, which is uncommon, as the head usually rotates during labour to a vertex presentation. After several hours of pushing and with a decreasing fetal heartbeat, the doctor decided that I should have a pudendal block (see Appendix A: Glossary of medical terms). My feet were placed in stirrups, medical attendants applied forceps and I was given an episiotomy to deliver the baby. I experienced a postpartum hemorrhage and a third-degree tear into the anal sphincter requiring an extensive repair of my perineum. I was unable to breastfeed due to sore nipples, which I felt as a devastating loss. I became anxious and depressed; a condition that was neither diagnosed nor treated. It was not until after many years of nursing experience and probing into existing maternity care practice—during which the issue of     5      difficult birthing experiences continually surfaced—that I reflected on my own difficult birth and from there to health care practices and women’s birthing experiences generally. Personal experience thus ignited my curiosity to explore the culture of birth and to question why and how things can go so very wrong. I became interested in the problems and aberrations of pregnancy, labour and birth and how they might be addressed. My focus extended to issues of loss and grief associated with childbirth and I investigated technological initiatives as they developed to see if they might improve outcomes for positive birth experiences for women. I also pursued further education, all of which culminated in my current focus on birthing and women’s experiences. Looking back, I thought about my own birthing and if other women’s experiences were similar. Questions tumbled over each other: What does it mean to a woman whose birth process becomes something she did not expect? What happens when clinical decisions are not shared or when the care she receives has the effect of disembodying her? How do women feel when their pain and the medical techniques used to deliver the baby seemed more like torture than help, when the risk of injury and death are real?  Unfolding the Narratives  Here I outline how resolving those questions informed my research and provide an outline of the research and analysis that follows. Chapter one introduces the literature on difficult and traumatic births. Chapter two features the epistemic and methodological considerations that explicate the importance of a feminist approach in this study on women and childbearing. I outline the central tenets of feminism to allow an appreciation of why feminist epistemology is critical when grappling with women’s experiences. I discuss the research approach, including my own position as the researcher in ethnography and the methods used for data gathering. I also explain data management, methods of analysis, rigour and the limitations of the study. Chapter     6      three introduces each research participant. In their own words, the women provide insights into their birth experience and how their difficult birth affected their mothering over the long-term. In chapter four I examine antenatal education and the care the women who participated in the research took of their pregnant bodies, antenatal medical care and the public pregnant body. I also include here the experiences of four women who experienced preterm deliveries and became mothers earlier than they planned. In chapter five, I highlight the stories of four other women; two women who gave birth without attending prenatal education classes and two who experienced an interventionist childbirth. In chapter six, I present the stories of three women who experienced medically managed births at term and of one woman who experienced post-term birth. Chapter seven unfolds the experiences of women who were left alone while in labour. In chapter eight the women participants share their feelings of guilt, love for their child, their sense of vulnerability during birth and how their experiences of difficult births stayed with them as they have matured. I describe the conceptual dimensions that arose from the research in chapter nine followed in chapter ten with a discussion of the concepts of reflection and reflexivity as documented throughout the work. This final chapter also provides my own conclusions and a discussion of the recommendations for change through themes of enforced silence; bullying, including being ignored or made to feel stupid; neglect; isolation; projected stigma; and, ethical issues identified by the women.  Significance of the Study There is currently a gap in our knowledge about how women’s lives are affected longitudinally following a difficult birth. My study intends to contribute information to childbearing women and families, nurses, doctors, midwives and other HCPs about women’s experiences of a difficult birth and how that birth affects them over their lives. The study     7      provides insights to current health care practices to shed light on personal experiences of birth with recommendations for improvement. Situated from a birthing woman’s perspective this work draws attention to the long-term impact of a difficult birth on the mother, the infant and the family.  Contributions to Knowledge  My research provides substantive contributions to understanding the untold stories of women’s difficult childbearing and resultant mothering and mothering behavior (Forrsen 2012). In addition to women sharing their stories—defined in their own terms how the births were difficult—the research probed the resultant connections women make with their children over time; a process about which little is known.  This research also contributes to understanding the treatment of women in health care settings and the actions of HCPs that can adversely affect women’s birthing experiences and the meaning they make of that birthing process (Creedy et al. 2000; Dahlke 2009; Davis-Floyd 2001). In surfacing this awareness raising these issues can raise the awareness of HCPs, who might reflect on their own actions in order to ameliorate or discontinue practices that are detrimental for women (Gamble and Creedy 2004; Gamble et al. 2005; Gavin et al. 2005). Awareness of taken-for-granted actions that can stimulate postpartum depression and post-traumatic stress may help HCPs, public health and hospital institutions to change previously held beliefs or practices to minimize trauma through changes in policy and trauma-informed care (Forssen 2012; Goodwin-Smith 2012; Seng et al. 2009; Seng et al. 2013; Soet et al. 2003). Furthermore, the recognition of difficult births and its sequelae by family members and community may help to prepare women and families for the changes that might follow upon a     8      woman’s experience of a difficult birth (Deave et al. 2008; Edoka et al. 2011; Elmir et al. 2012; Emmanuel et al. 2011; Field 1998).       9      Chapter 2 Positioning the Study This chapter explores pregnancy, becoming a mother, the qualities of a “satisfactory birth experience” (Hodnett 2002:160) as well as an unsatisfactory birth experience. The main purpose of this literature review is to provide an overview of current thoughts about childbirth, expose gaps in knowledge about difficult birthing experiences and illustrate where my work fits in.  There is a disconnection between what has been written and the actual experience of motherhood (Arendell 2000). Numerous writers have explored topics related to the physical and psychological aspects of childbearing (Ayers and Pickering 2005; Beck 1995, 1996, 1998; Bewley and Cockburn 2002; Hodnett 2002; O’Brien 1989). Many professionals espouse support for women-centred care during labour, birth and childrearing (notably Kitzinger 1987a, 1987b; Oakley 1980; O'Brien 1981; Rothman 1984; Simkin 2004) and women have written about their lives as women and as mothers (see Atherton 2007; Bergum 1989; Chodorow 1978; Heilbrun 1988; Owens 2008; Rich 1979). Mothers have handed down knowledge, from generation to generation, through oral history in stories and fables (Carpenter 1985; Dworkin 1974; Gluck and Patai 1991). However, while many of these stories reflect an ideological position, few pose the question of what the impact of a difficult birth might have on a woman. Despite the disinclination of HCPs to discuss and include prevention strategies for a difficult birth experience during education and prenatal care, women imagine and idealize their birthing experience. By “difficult” birth I am referring to births that may occur from unavoidable events such as a prolapsed cord, fetal distress, maternal conditions and other complications. In addition, difficult births may also be a consequence of the initiation of questionable interventions and the knowledge that once interventions are implemented often lead to more intervening activities     10      (Lothian 2006a; Romano and Lothian 2008). Both unavoidable and avoidable interventions will be described as part of the women’s difficult birth experiences. Pregnancy and Becoming a Mother: A Socio-Cultural Perspective As women, we share expectations of ourselves in order to fulfill the socio-cultural ways of being both women and mothers in the Western world. As mothers, women are expected to care for their children to adulthood. Yet little education, if any, is provided for the woman in order to be a “good mother” in our culture (Choi et al. 2005). Sitcom television mothers, including icons such as June Cleaver, Carol Brady, Kitty Forman and Marge Simpsoni  have shaped Western images of what a mother is supposed to look like. She is a woman who is coiffed and dressed immaculately; who cooks, cleans and bandages cuts; smiles and takes care not only of her children but all the members of her family. The heart of the message is that a good mother-wife performs all these duties to support her home and family. Mother is house proud and “sexy” and women, children and men watching these media images internalize the messages.  Currently, reality television offers images and stories that dramatize intimate details of women’s experiences of birthing. The popularity and ubiquity of these narratives give the impression that surgical approaches to birth are typical and risk free. The choices women are making about their bodies have been standardized by the everyday acceptance of interventionist obstetrical care seen in tabloids and newspapers. There is normalization and a familiarity with the surgical process that allows women to select these approaches for themselves.  Looking at more drastic approaches to childbearing, in 2009, a 60-year-old Indo-Canadian woman gave birth to twins she conceived through in vitro fertilization done in India. She delivered her children by caesarean section seven weeks preterm in Alberta (CTV News 2009). One month prior to the births in Alberta, a woman in California gave birth to octuplets     11      after receiving fertility treatments. These babies were born via cesarean section nine weeks premature. The mother now has 14 children and her fertility treatments have led to an international debate about a woman’s “right” to bear children. These examples are extreme and contest the boundaries of societal acceptance and medical technology.  Yet, after a woman has borne a child she is viewed as the “primary and uttermost source of that child’s good and evil, its survival, health, sanity and selfhood” (Rich 1979:264). According to Rich (1979), society penalizes some children because they do not fit into an idealized mould resulting in a sense of worthlessness. Society lays blame for the waste of a child on the “bad” mother who has failed as a superwoman and failed to rear her child as well-adjusted, obedient, achieving and non-alienating (Rich 1979). The backlash of blame is evident in the words and accusations leveled at mothers as well as their children (Jackson and Mannix 2004). Often women are blamed for their own difficult or traumatic births— also informed by myriad messages, images and representations from oral histories and storytelling usually not from the woman who lived these experiences. Child rearing practices, child play, expectations and assumptions that are supported on an intergenerational basis are presentations of “rightness.” The meanings of failure are also insidious messages that are shared as women’s lore and reflected as “horror” stories of pregnancy and birth with little association to actual women’s experiences.  Becoming a mother is a life altering experience (Dahlke 2009) marked by physicality and a deeply personal way of knowing (Carpenter 1985). During pregnancy women invariably try to live up to perceived social expectations, assessing the availability of emotional and financial help, the burden of household tasks and infant care before her (Green 2003). In addition, women are under an extraordinary amount of scrutiny from their partners, family, friends and even     12      strangers (Bowman 2006; Callister 2001). This scrutiny involves monitoring weight gain, how the woman is carrying the foetus, whether she is eating right and other physical changes. The woman imagines her ideal birth experience and how she sees herself as a “good” mother (Mercer 2004, 2006; Sandelowski et al. 1994).  Today, women look to the health system for information and care during pregnancy and birth. In Canada, pregnant women have been enculturated to seek primary antenatal care from a general practitioner, obstetrician or more recently the midwife (Bourgeault and Fynes1997). The medicalized system of childbirth has only been in existence for the past several centuries.   Historical records depict the slow and gradual take-over of childbirth from early midwives, to barber surgeons then later to obstetricians and with these changes birthing moved from the home to the hospital (Brodsky 2008; Ehrenreich and English 1973; Donegan 1978; Donnison 1988; Wertz and Wertz 1989). This was a political move that took many decades to achieve through the elimination or outlawing of midwifery and through denial of midwives to formal education (Donegan 1978). Birth was seen through the lens of the patriarchal medical system as a pathological state that needed to be cured and thus the take-over of child birthing was achieved (Brodsky 2008).  Throughout time, women have helped each other during birthing (Ross Leitenberger 1998; National Aboriginal Health Organization 2008). During the early history of Western colonization in Canada, midwifery was formally recognized and regulated for many years and throughout various provinces. In 1912 the Medical Council of Canada was formed, which unfortunately eliminated the practice of midwifery in most locations. It was not until 1993 that Ontario legalized the registration of midwives. In 1995 British Columbia permitted the registration of midwives through legislation and regulation to care for childbearing women     13      (College of Midwives of British Columbia nd). Up until this time, Canada was one of a few developed countries that did not recognize midwifery.  Many similarities exist in education for doctors, nurses and midwives with the goals of working with women who are giving birth yet a hierarchy within the various roles of care providers still exists (Brodsky 2008; Kalisch and Kalisch 1977; Salvage and Smith 2000; Zelek and Phillips 2003). In the past, nurses were seen as being the handmaidens to physicians with nurses lesser knowledge, gender and unequal power as the basis for these differences (Ehrenreich and English 1973; Kalisch and Kalisch 1977; Wertz and Wertz 1989). Today with nursing degrees as entry to practice the differences of unequal power should be decreasing and the narrowing of the educational gap has not had a significant effect on the development of mutual respect (Davies 2000; Kalisch and Kalisch 1977). With the most recent inclusion of midwives into the Canadian health care setting their role is also under question and collaboration is inconsistent (Homer et al. 2009; Larsson et al. 2009). Midwives have been seen by physicians as competing for clients and working effectively together “is limited both by tensions over role boundaries and power and by incivility that is intensified by increasing workloads and a fragmented labour force” (Reiger and Lane 2009). Conversely, physicians in most Western countries today enjoy the income, prestige and authority which “reflects their omnipotence amongst health care professionals and their power within our society” (Zelek and Phillips 2003:1). Veiled conversations and suggestions are seen in journals alluding to the disharmony between HCPs suggesting that HCPs should “work together” rather than “working alongside” one another for patient safety and the best outcome for mothers and newborn (Davies 2000).  The relationship between HCPs, the woman and her family is a critical factor that can affect the level of “satisfaction” a woman feels about her birthing experience (Hodnett 2002).     14      However, HCPs often hold different perspectives and philosophies about birthing that can create a disconnection between mother and care providers (Chalmers et al. 2001). Statements such as “If the baby is born alive and the mother is healthy; what more can the parents ask for?” are commonly heard coming from HCPs (Carlton et al. 2005:149). However, for a woman these aspirations of a live baby and mother may not be consistent with her own vision for her birthing experience (Dagan et al. 1999; Hodnett 2002).  Women construct an ideal for their birth experience imagining a care provider of her choice, a supportive and loving partner by her side, family members who offer additional care and nurturing, as well as safe delivery of her unborn child. Prenatal education class videos depict the birth as, ideally, a positive and empowering experience for women, the mothers expect that their choice and wishes in their birth plan, which were discussed during pregnancy care, will be recalled and respected by those providing care (Kitzinger 1978; Simkin 1991). For some women these images of their ideal birthing experience and motherhood dreams are not fulfilled leaving women feeling they have failed (Pincus 2000). Qualities of a Satisfactory Birth Experience Hodnett (2002) describes four factors that define women’s satisfaction with the experience of childbirth. However, “satisfaction” is not a term I have ever heard used by women to describe their birth experience. Satisfaction, according to Hodnett (2002), is the fulfillment of personal expectations; the amount of support received from caregivers; the quality of the caregiver-patient relationship; and, involvement in decision making during birthing. Having a voice and participating in decision making appear to be so important that they override “the influences of age, socioeconomic status, ethnicity, childbirth preparation, the physical birth environment, pain, immobility, medical intervention, and continuity of care, when women     15      evaluate their childbirth experiences” (Hodnett 2002:160). A synthesized review of research on psychosocial factors that influence the outcome of labour and childbirth, by Howarth et al. (2010) found that women who had continuous one-to-one support, they experienced  lower pain, fear and anxiety, as well as greater satisfaction with the labour and birth. When women consistently saw the same care provider throughout their pregnancies and births, they were more satisfied than women who saw a number of different professionals (van Teijlingen et al. 2003). In a study in Ireland, Cronin (2003) used in-depth interviews and focus groups to examine experiences of giving birth, and identified the importance of support from lay networks, health care professionals and other services such as public health as significant issues.  Cronin also identified support for breastfeeding, the mother and child relationship, coping and psychological strategies for depression, frustration and loneliness as central for the women.    One of the issues identified in the literature about women’s lack of satisfaction during their birth experiences is how a mother works through her birth experience over time and how dissatisfaction affects her mothering. Consistent with other work on birth satisfaction, Hodnett (2002) reports interviews with new mothers are often conducted while the woman is still in hospital. Women may not be at their best during the early postpartum period and the full impact of the experience may not have fully registered with them yet. However, Hodnett (2002) did find that participating in decision making and having a voice are leading determinants in defining satisfaction with one’s birth process. Thus, a major source of childbirth dissatisfaction, that is, not being informed and not having a say or choice in how their births progressed is not being heard. Women’s points of view are marginalized and the omissions of choice and voice are read as dismissive and oppressive thus rendering women silent. When women’s voices are silenced by care givers avoiding negotiation and spending time sharing information and decision making,     16      this allows the medical system, as an institution, to run smoothly. The literature suggests that women’s subjectivity is minimized at best and absent at worst (Brodsky 2008; Davis-Floyd 2001). Women’s bodies, whether pregnant or not, have been the object of male fascination and obsession (Goodwin-Smith 2012) and pregnancy has been described as a social construction of illness that has been pathologized and treated and administered as “otherness via the professional representations of the modern expert” (527).  How a woman sees herself becoming or being a mother often reflects how she was mothered (Carpenter 1985; Rubin 1967a, 1967b). Thus, the understanding and knowledge a woman brings to motherhood are influenced through the interplay of factors over her life span (Logsdon and Gennaro 2005; Misra et al. 2003). A woman’s attitudes towards mothering develop as a result of the interaction between biological and environmental variables in her life (Evans and Stoddard 1990), including the cultural beliefs and images depicted in the media. For instance, many girls play with dolls mirroring maternal roles and modelling what lies ahead. These dolls assure enculturation of girl children into our gendered cultural roles that see a mother not only as having a child but also as a person who socializes and nurtures (Chodorow 1978). Socialization into motherhood includes the role of primary parent or caretaker and mothering is also central to the sexual division of labour (Baines et al. 1991; Chodorow 1978). Although some men in contemporary society also provide childcare, there are important role differences. In heterosexual relationships men often have more choice about the caring work they undertake. Moreover, the concept of “maternal bonding,” is a key concept that has fuelled the ideology of motherhood (Baines, et al. 1991; Mercer 2004; Rubin 1967a, 1967b).      17      Attachment Theory  Early work by Bowlby and others describe the deep feeling parents have for their children (Ainsworth 1964; Bowlby 1997; Vaillant 1985) and the damage that occurs when a child experiences loss or a lack of attachment. It is believed that the attachment that is formed in infancy will help to shape the attachment relationships people have as adults. Meeting an infant’s first basic needs, a prerequisite for optimal development, is the basis for secure attachment to a primary caregiver (Steinhauer 1998). Attachment is the bond of caring that ties child and caregiver to each other and once formed the attachment persists despite temporary absences of the primary caregiver. Harris (1998) disputes Bowlby’s claims of kind, honest people will have kind, honest children and those disreputable parents who are rude and liars will have children that are the same way. Harris (1998) maintaining that this may not be the case and proposes that parents do not entirely shape their child’s personality or character and that peers have more influence on them than their parents. For example, take children whose parents are immigrants where the child continues to speak the native language at home, but can also learn their new language and speak it without an accent, while the parents’ accent remains. Children learn skills from their peers because they want to fit in (Harris 1998). Field also argues against attachment model stating that mothers are not the only individuals that infants and children are attached. Children may well exhibit crying and attachment when a sibling or peer get ready to leave them and may become just as fussy or unable to sleep (Field 1996). In addition, another limitation to the attachment model is that the mother is viewed as the primary attachment figure, when in fact; a partner or other family member can have the same type of attachment with the infant at the same time (Field 1996).      18      The development of attachment occurs for mothers and other family members with accompanying deep feelings and craving for the child that is often referred to as love. Maslow’s (1943) hierarchy of needs outlines the necessary requirements for human development of which love and a sense of belonging are foundational for each individual.    After giving birth, mothers often describe an intense, immediate love for their child and I have often amazed how women fall in love with their child at first sight. Hormonal influences of oxytocin aid and stimulate these feelings of early love or attachment reinforced by cultural expectations and societal norms in shaping a woman’s expectations of herself to love her child. For some women and men these feelings of love begin prior to birth and grow with time (Condon 2012; Deutsch 1944; Winnicot 1958). Early dependence and the helplessness of a newborn add to a parent’s sense of caring and devotion. Rich (1979) describes her feelings toward her first child and critiques the lack of information about the psychic crisis and the feelings of being taken over by love. She notes that the “new physical and psychic potentialities ... [and] heightened sensibility … can be exhilarating, bewildering and exhausting” (17). Further she points out that, no one “mentions the strangeness of attraction–which can be as single-minded and overwhelming as the early days of a love affair–to a being so tiny, so dependent, so folded-in to itself–who is, and yet is not part of oneself” (17). Unfortunately, with advancing technology, the structure of health care experiences and the processes of hospital practice have changed birthing processes and some women’s experiences of birthing.  I now turn to the structure of health care experiences and the processes of current Canadian hospital practices to gain a sense of how birthing has changed with science and advancing technology.         19      Medical Control of Childbearing: Caesarean Births  Health care today in Canada is experiencing cultural, social and technological changes that have further influenced birthing practices. Hospital procedures and processes are privileged and oppressive: privileged in that they support the workings of the institution rather than the woman receiving care and oppressive due to their lack of a women-centred approach (Farmer 2004; Goodwin-Smith 2012).  There is an increasing rate of caesarean births (Lowe 2013). The argument for caesarean sections is framed as permitting women to schedule the most convenient date for the birth. More often obstetricians prefer cesarean sections as they are more convenient as they can be done in day-light hours and more suited for scheduling their office hours. For doctors, scheduling a birth, rather than being called in the middle of the night is one consideration, but financial incentives are a big factor, since caesarean sections are lucrative for physicians and private hospitals because a greater number of births can be performed during one work shift. Also avoidance of malpractice suits is important to doctors because the birthing time is considerably shortened and there is a perceived decreased risk of complications; thus, litigation is avoided (Davis-Floyd 1993; Munro et al. 2009). Caesarean births also increase health care costs exponentially. Women in North America have been enculturated to view surgical birth as an easier way to have a child, avoiding the pain and “messiness” of birth (Bryant et al. 2007). Women are choosing caesarean sections (Klein 2004) in the belief that caesarean are safest for the baby (Munro et al. 2009; Ryding et al. 1998). However, caesarean birth is major surgery, an invasive procedure that holds considerable risk (Declercq et al. 2005; Ecker and Frigoletto 2007; Liu et al. 2007; Liu et al. 2002). Today, caesarean rates in Canada and the United States are approximately 30 per cent (Liu et al. 2007).      20      The World Health Organization suggests that caesarean section rates higher than 15 percent cannot be medically justified (Gibbons et al. 2010). Countries whose caesarean section rates exceed fifteen per cent include the United States with 30.3 per cent, Australia with 30.3 per cent, United Kingdom at 22 per cent and Canada at 26.3 per cent (Gibbons et al. 2010). The escalating caesarean rate in the developed world contrasts sharply with estimates of around one to two per cent in very poor countries (such as sub-Sahara Africa, see Gibbons et al. 2010) where access to medical technology is limited (Dumont et al. 2001). Yet the proportion of women in developing countries needing a caesarean section is theoretically higher due to poor prenatal care and greater obstetric risk (Dumont et al. 2001). Women in Canada have access to publically supported prenatal health care through a system of universal medical coverage. Early health care during the prenatal period assists in the detection and prevention of problems in later pregnancy and delivery (Hudelist et al. 2008; Kalyanadrishnan and Scheid 2006; Richards 2009). In Canada today, we should be seeing fewer operative births; yet, the opposite is true. While rising rates may be due to women electing to have caesarean births or women being coerced into believing it is the best and easiest way give birth. Investigations in Canada show recent and unexplained increases in frequency and severity of postpartum hemorrhages (Joseph et al. 2007) that suggest childbirth practices may be causing such complications. Women in developed countries and in some developing countries are undergoing and demanding caesarean sections to avoid the perceived risks of vaginal childbirth (Fenwick et al. 2010; Hopkins 2000; Hsu et al. 2008; Karlstrom et al. 2010; Kelly et al. 2013; Lee et al. 2001). Increasing rates of caesarean births have been explained in term of biological deviances, or individual desire by both women and obstetricians. This complex phenomenon is reduced to     21      explanations that originate from beliefs held by each individual and deny the influence of social contexts. Caesarean births have become medical phenomena and are produced, at least partially, through social belief systems (Bryant et al. 2007). These social contexts include the recognition that caesarean birth is structured by broader gendered power relations with the obstetrician having greater decision-making for when and how these surgeries are performed (LoCicero 1993). In other instances women who are employing new medical technologies for pregnancy and surgical births can be seen as a marker of choice, conferring a sense of empowerment and social status (Behague 2002). However the rising surgical birth rate and the impetus to contain health care costs may drive the need for research aimed at promoting vaginal delivery (Johnson and Wiencek 2005), albeit from a different ideological perspective. Women’s bodies, seen as objects through operative births, take away women’s participation as well as their subjectivity.  In my own practice, women have reported to me that they “don’t feel like a woman” following a forceps birth or an emergency caesarean birth. After surgical interventions, women question themselves, their bodies and their ability to have a vaginal birth. These comments translate as a loss of self-esteem and a lost opportunity for an empowering female experience (Callister 2004, 2006; Page 2004).  Operative Births in British Columbia (B.C.) The Canadian Institute for Health Information (2013) reported an increase in the number and rate of births by caesarean across the country. By 2010 caesarean birth rates in Canada have “increased to 26.9% from 17.6% in 1995” (Kelly et al. 2013:207). This means that, on average, one in four Canadian women will have a caesarean delivery (British Columbia Perinatal Database Registry 2011). Among the provinces, Newfoundland and Labrador and B.C. continue to have the highest primary caesarean rates (21.1% and 22.4% respectively), while Manitoba and     22      Quebec had the lowest rates 14.2% and 15.3% respectively (Canadian Institute for Health Information 2013).  The British Columbia Perinatal Data Registry summarized their findings over the ten years from 1995-1996 to 2005-2006:  Over this time there has been an average of 40,000 births per year. During this time the rate of spontaneous vaginal delivery decreased from 64.2 to 60.1%; the rate of assisted vaginal delivery, including vacuum and forceps intervention, decreased from 12.2 to 10.4%. The provincial Caesarean section rate rose from 23.6 to 29.5% (BC Perinatal Health Programs, Executive Summary, Caesarean Birth Task Force Report 2008:5). Clearly, there is a continual increase in unexplained high risk caesarean deliveries in the province of B.C. where numbers have increased steadily and significantly from 27.1 per cent in 2001/2002, to 31.0 per cent in 2010/2011 (Perinatal Services of British Columbia 2011). This means that in 2009/2010, the B.C. rate of 30.3 per cent was 13 per cent higher than the Canadian rate of 26.8 per cent.  Caesarean births are performed for a variety of reasons, such as a foetus too large for the pelvic opening, fetal distress, or following a failed induction (British Columbia Perinatal Health Report, Caesarean Task Force, 2008). Other complications—separation of the placenta from the uterus prior to the birth of the infant, a cervix that does not dilate, a foetus that does not descend within the pelvis—increase the risk of surgical birth (Davidson et al. 2012). Other indications include breech presentation (Kotaska 2004; Kotaska et al. 2009), twins, previous caesarean birth (Behague 2002; Hildingsson 2008) and obesity (Davidson et al. 2012); although for these conditions the research suggests that vaginal birth would be a reasonable choice for some of these women (Lothian 2006b). Some obstetric situations are emergencies (such as abruptio     23      placenta and placenta previa) and, in these situations, caesarean birth often saves the lives of both mother and child. While other complications are infrequent; however, women are unwilling to take risks and therefore request a caesarean birth for the health of their unborn baby and care providers respond. Birth moves from a normal physiological process to an orchestrated process of high risk surgery, thereby changing the dynamics of the birthing experience. As more women request a caesarean birth prior to the onset of labour—termed “caesarean on demand” (Lothian 2006b)—high risk surgical birth becomes a legitimate norm. The move from a vaginal birth to surgical intervention affects the outcomes of labour and birth and ultimately reduces a woman’s level of wellness after birth (Davidson et al. 2012).  Unsatisfactory Birth Experiences Despite modern medical technology and increasing surgical interventions, women experience births that are less than optimal. Indeed, health professionals are seeing an increase in the number of women who experience great dissatisfaction following childbirth (Beck 1995, 1996, 2001; Kitzinger 2006; Romano 2006). Women who have experienced difficult birthing may display a sense of bewilderment, express feelings of unresolved loss, weep and manifest other symptoms of deep emotional trauma (Beck 2001; Beck et al. 2011a, 2011b; Figueiredo and Conde 2011). There is a growing link between women’s experience of an unsatisfactory birth and the instances of postpartum depression (PPD) and posttraumatic stress disorder (PTSD) (Creedy et al. 2000). An increasing number of women are taking antidepressant medications prior to birth. These medications may be prescribed for myriad reasons including reasons due to PPD triggered by a previous birth (Logsdon et al. 2006), or after a difficult birth (Goodman et al. 2004; Misri 2005; Soet et al. 2003).      24      Birth has been studied and described as a negative event (Waldenstrom et al. 2004). Their experiences of negativity have been associated with excessive pain (Lowe 2002) or fear of childbirth (Fenwick et al. 2009; Nilsson and Lundgren 2009). The meaning of women’s experience of childbirth fear, according to Nilsson and Lundgren (2009), is “to lose oneself as a woman into loneliness” accompanied by feelings of danger and pain that threatens the loss of self-identity (4). Other negative birth experiences include sudden birth complications (Wilde and Murray 2009) such as an emergency caesarean section or instrument birth when accompanied by dissatisfaction with intrapartum care have shown to result in increasing rates of PPD and PTSD after childbirth (Creedy et al. 2000). Women who experience a preterm births (Bick 2012; Wood and Quenby 2011) or other life threatening complication for themselves or their newborn also experience higher rates of PPD and PTSD (Elmir et al. 2012; Hunter et al. 2008; Oyelese and Smulian 2006: Williams et al. 2005).  A traumatic response can occur immediately following birth or be delayed to surface at some later time. With negative birth experiences feelings of pessimism, however, do not diminish (Howarth et al. 2010; Simkin 1991, 1996). Following a difficult birth, women survivors of sexual abuse, incest, PTSD and other mental health concerns may suffer from depression or re-traumatization (see Ayers 2007; Beck 2008a; Gamble and Creedy 2004; Klaus 2010; Kulkarni 2014; Leach et al. 2014; Leeners et al. 2006; MacKay and Rutherford 2012; Misri 1995; Mollard 2014; Onoye et al. 2009; Parfitt and Ayers 2009; Parratt 1994; Rose 1992; Rouhe et al. 2011; Seng et al. 2009, 2014; Simkin 1992a). Research in clinical psychology has indicated that understanding predictors and triggers to PTSD following traumatic birth through a process of describing and evaluating counseling for women for its efficacy is in order (McKenzie-McHarg 2004). Other areas for further investigation is the elaboration of other predictors, such as     25      psychosocial and cognitive factors in addition to a complete understanding of the best methods and timing of measurements of PTSD also requires further investigation (McKenzie-McHarg 2004). Researchers are just beginning to identify strategies to assist women in the antepartum and postpartum periods to identify strategies to assist or prevent these occurrences in women’s lives and in the lives of their families (Ayers et al. 2006; Clatworthy 2012; Figueiredo and Conde 2011; Letourneau et al. 2012). There is preliminary evidence indicating that interventions delivered in pregnancy can be effective in preventing PPD when based on psychological therapies and treatments are better conceptualized early in pregnancy rather than preventive interventions (Clatworthy 2012). In addition, treating the entire family has also been strongly recommended in the identification and treatment of PPD (Letourneau et al. 2012; Zauderer 2014).  The polarities of satisfactory and traumatic births have been studied, as well as the broad middle ground of investigations on various aspects of pregnancy, prenatal care and education, labour and birth. However, few studies have looked at what the meaning of difficult birth is for women and when “difficulty” is mentioned the topic usually refers to traumatic births.  One-third of Euro-American women evaluate their experience of childbirth as traumatic, giving examples of having been dismissed, treated without dignity and ignored (Ayers et al. 2006; Forssen 2012). An estimated 19 per cent of women will suffer with PPD during the first year after birth (Gavin et al. 2005) making this “the most common complication of childbirth” (Beck 2008a:122). The idea of childbirth complication frames the event as medicalized and does not consider the social context in which a woman experiences PPD. Medicalization moves the experience of PPD into an arena as something other than a normalized childbirth (Graham and Oakley 2005). The challenging role transition for the new mother is exacerbated by the     26      experience of PPD and there are serious psychosocial consequences for a woman and child (Deave et al. 2008; Field 1998).  Simkin (1991) conducted a retrospective study of women and their perceptions and recollections of their birth process. Simkin taught childbirth classes during the late 1960s and early 1970s to the women participating in the study and interviewed the women 20 years later to access their recollections of birth over time. The results from the study showed the women held vivid and detailed memories of their birthing. Simkin claims that childbirth has a powerful effect on women and has “the potential for permanent or long-term positive or negative impact” (210) on the lives of women and how they see themselves. As a woman recollects her caregiver forever, “the question that should be kept in the caregivers mind at all times is ‘how will she remember this?’” (Simkin 1991:210). Furthermore, caregivers need to remember that they represent authority figures during this vulnerable time in a woman’s life and their actions can “contribute directly to her long-term satisfaction and indirectly to her self-esteem” (210).  Birth trauma and its sequelae can extend beyond the postpartum period into an unknown future. These experiences of birth and how a woman mothers following a difficult birth have been portrayed through the diagnosis of PPD and PTSD.  Women’s Birthing Experience: Trauma and Post-traumatic Stress Disorder Trauma and traumatic memory have been a focus of psychiatry, cognitive science and neuroscience for approximately the past 100 years or so (van der Kolk 1987; van der Kolk et al. 2001). The awareness or retrieval of lost memories has also extended knowledge about the relationship among stress, memory and traumatic events.   In 1980, posttraumatic stress disorder (PTSD) was first included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) (American Psychiatric Association [APA],     27      1980), thus legitimizing experiences of trauma on an individual’s life. The DSM-IV provided a broadened view of what constituted an extreme traumatic stressor, including “direct personal experience of an event that involves actual or threatened death or serious injury, or a threat to the physical integrity of the self or others” (DSM 1994:424). This broad range of qualifying traumatic events, with the added criterion of a specific emotional response, deemphasizes the objective features of the stressors and highlights the clinical principle that people may perceive and respond differently to similar events. This criterion established a category for trauma and its consequences following a difficult birth.   Researchers have studied traumatic aspects of the birthing process, including risk for postnatal emotional distress (Callahan and Hynan 2002), prevalence and prediction of posttraumatic stress symptoms following childbirth (Czarnocka and Slade 2000), PTSD in women who have undergone obstetric or gynecological procedures (Menage 1993) and, PTSD after childbirth (Beck et al. 2011b; Marrs 2013; Modarres et al. 2012; Thurgood et al. 2009). To date, no information or research has been found on the impact of a difficult birth on mothering over time.  As noted previously, in Canada an increasing number of women are experiencing instrumental or caesarean births. Similarly, an increasing number of women are taking antidepressants prior to and following giving birth. Evidence  suggests that fewer women are having a positive, empowering birth experience and an increasing number (more than 19.2%) of women are suffering from depression following birth and some having traumatic birth experiences (Beck 2004a, 2004b, 2006).  Even though birthing emergencies resulting in surgical intervention are becoming more common, they are, in themselves a source of trauma (Creedy et al. 2000). Trauma during or     28      following birth has been described and studied by nurse researcher Beck (1995, 1996, 1998, 2001, 2006), who has helped to identify and extend understanding women’s experiences following a difficult birth in both the United States and Australia. Birth trauma involves experiences that “may occur during any phase of childbearing … the trauma may be classified as a negative outcome, including a stillbirth, an obstetric complication (e.g., an emergency caesarean) or psychological distress (fear of an epidural)” (Beck 2004a:212). A more extensive list of birth traumas include infant death, emergency caesarean delivery and/or fetal distress, cardiac arrest, inadequate medical care, congenital anomalies, inadequate pain management, manual removal of placenta, forceps, vacuum extraction and/or fetal skull fracture, separation from infant in the neonatal intensive care unit, prolonged painful labour, rapid delivery and degrading experiences (Beck 2004a). With all these bodily changes and adaptations in pregnancy I wish to ask, how does a traumatic memory impact one’s sense of motherhood? Structural Violence  Difficult births may be framed as “structural violence,” that is, the absence or lack of care and attention by social agencies that are intended to serve others (Galtung 1990). Farmer (2004) describes structural violence as a social arrangement that places individuals in harm’s way. The arrangements “are structural because they are embedded in the political and economic organization of our social world and … violence because they cause injury to people” (Farmer et al. 2006:1686). Furthermore, structural violence is often brought to bear on those people whose social status lacks empowerment. The organization of the health care system has been constructed on the basis of scientific and social progress privileging biological investigations over human experiences of suffering (Farmer 2004). Included within the structure is an acceptance of care meted to those seen as     29      needing care as well as justification for those disadvantaged from receiving care. In most hospital systems unequal distribution of power (Ho 2007) is a consequence of direct or indirect human agency (Farmer 2006) and the inequities that exist are the underlying problems for particular groups. The idea of structural violence is linked very closely to social injustice and the social machinery of oppression (Farmer 2004; McPherson 2012). McPherson (2012) has studied violence and finds that violence is about “power differences and power inequities are a necessary and sufficient condition for violence” to be perpetrated on another (37).   For birthing women structural violence may be seen as the increasing use of surgical births without adequate evidence that these types of birthing procedures are needed, in not informing women about treatment, or by treating women in a less than humane manner. More will be said on structural violence later in the paper.  Baby as Product The experience of pregnancy for the woman is a life transition. A woman becomes pregnant, experiences nine months or so, of changes in mind and body, labours and gives birth from her body. When described this way we see the woman as object, a separation of the mother’s birthing (process) from the baby (product) and the baby as object.  New ways of “seeing” the body produce new ways of experiencing the body. Technology allows us to penetrate that once secret enclosure of the uterus to expose the image of the foetus to public gaze, eclipsing the pregnant woman in the public mind (Duden 1993). Anxious, perhaps, about the health of the global environment, medical science and technology has focused on protecting life in the maternal ecosystem, which can pit foetus against mother such as restrictions placed on women in regards to their activity, their work environments and what they eat, as well as women with addictions to alcohol or drugs or any activities that are seen as harmful (Roth     30      2000). This adversarial relationship occurs not just within the female body but outside of the body, through dialogue by others who wish to control women and their reproduction (Moore et al. 2010). The church, legal system and societal ideologies have supported the ownership of women’s bodies, first by the father and later by the husband. The mystery of childbirth and its powerful function in society have always been a frightening concept for men (Keen 1992). The control of women through laws and church reinforced the dogma of male control.  The history of “ideological gynecology has now led us to the epoch of fetal dominance” (Duden 1993:99). The visible image and appearance of the foetus has colonized discourse, vision and even the experience of the potentially or actually pregnant woman. The foetus threatened by extinction is used as a signifier, an instance, a news-hook, or an emblem of a much more general statement about endangered life (Duden 1993). Women, Mothering and Being Female Women have been associated with “nature” and an essentialized biology, an affiliation that has persisted “through culture, language and history” (Merchant 1983:xix). As most of the people taking up the work of mothering have “had female bodies, mothers, taken as a class, have experienced the vulnerabilities and exploitation as well as the pleasures of being female in the ways of their culture” (Merchant 1983:41). However, an expectation of many cultures is that many more women than men who have not actually become mothers “are still expected to engage in maternal work or identify with those who do” (Merchant 1983:43). “Maternal” is associated with women and many “men will not identify with it even though they may be behaving in ways that have traditionally been seen as feminine” (hooks 1984:138-139).  Mothering is inseparable from the condition of being female.     31      Surveillance: Medical Gaze of the Female Body Margaret Atwood raises a series of questions that speak to the body under gaze and the terminology or naming that is assigned to describe birth:  Who gives (birth)? And to whom is it given? Certainly it doesn’t feel like giving, which implies a flow, a gentle handing over, no coercion … Maybe the phrase was made by someone viewing the results only … Yet one more thing that needs to be renamed. (Atwood 2001:311) The idea of “view” or “gaze” in Atwood’s writing provides the onlooker with a different and distinct notion of birth compared to the woman experiencing birth. To gain a true understanding of childbearing it is essential to speak to a woman about her birth experience. However, the notion of a woman’s perceptions or experiences of birth and hospitalization is rarely covered in textbooks. Much of the information about the person is from the perspective of the trained observer or helper and can be termed as surveillance. Surveillance is defined as the information and perspective gained from watching another. The term “medical gaze” was coined by French philosopher and critic Michel Foucault in The Birth of the Clinic (2003), to denote the dehumanizing medical separation of the patient’s body from the patient’s person or identity through surveillance. When seen through the medical gaze, “women’s problems” (read reproductive health) are described as pathological (Theriot 1993) and hysterical (Birnbaum 1997; Freud 1962). The concept of surveillance is addressed throughout the work.  Today’s sense of privacy and decorum in Western society looks very different. Music videos and films offer a wide-range of visual imagery and states of undress where women are scrutinized and watched by others. Women’s bodies are depicted, not as a whole but in parts. Women then are understood as not being complete and being less than fully human and women     32      experience an uneasy citizenship (Boston Women’s Health Book Collective 2005; Canadian Women’s Health Network 2014). Influenced by fictionalized images, women have their own negative sense of their bodies (Bordo 2003). Societal and media images are juxtaposed against my own experience of women’s sense of privacy. When caring for mothers during childbirth, I have frequently heard women describe intense shyness and great fear that their genitals may be unnecessarily exposed. This sense of vulnerability requires that extra effort must be taken to respect a woman’s wishes and to preserve her dignity.  The arrival of the doctor, at the bedside, brings with it the medical gaze. The medicalized view is a stance much different from the woman’s perspective. The medical gaze or surveillance involves seeing the woman as something to cure, to minister to and maneuver. Seeing the woman and her foetus as “patients,” objectifies them through the scientific lens that defines reproduction as a biological defect (LeMoncheck 1996). Modern medicine is almost entirely preoccupied with diseases and treatments and very little is focused on health (Connors 1980). The seizure and medicalization of pregnancy and childbirth by men “are rooted in the patriarchal model that has been centuries in the making” (Cahill 2001:334). Childbirth is seen as pathological with women’s bodies as inherently defective and these beliefs continue to shape women’s position in society and are monitored through acts of surveillance. The image of the female body when viewed at delivery shifts when the physician enters the delivery room. All attention is now moved from the labouring woman to the doctor. The physician needs to prepare, to scrub and glove and may don a sterile gown (with the nurse’s assistance) and ready the equipment used for the delivery. He or she asks for topical anaesthetic agents, their preferred suture materials and inquire which paediatrician is on call. It is almost as if the work is now legitimate: the doctor is here and the real work can begin.      33      When the physician enters s/he disrupts the individuals and family who are attending the woman. At this moment the physician identifies the woman’s need for assistance and for interventions facilitating the birth that keep the gaze focused on the woman’s genitals. The hours of interaction and caring (Meleis 1997) for the woman and her wishes such as birth plan requests, family supports and needs have been provided by others. Medical surveillance—like science—is relieved of personal knowledge and emotion, is clinical and objective. After the woman has given birth, she often profusely thanks the physician for “delivering” her infant. In fact, she delivered her own newborn (Hunter 2006) through tremendous efforts of her body and mind and with the continuous help and support of the nurses and family who have been with her since her first contractions. If the doctor had not arrived for the delivery, the nurse would have helped the woman give birth, a situation referred to as BBA or “born before arrival” of the physician; yet the physician is still paid for the delivery. The work and travail that has occurred throughout the labouring process is measured in terms of the doctor’s participation through validation of his or her surveillance.   Rothman (1984) describes the terms to be delivered or to give birth. When the mother is seen as “giving birth,” an attendant is assisting, aiding and literally being present for the woman. But when the doctor is present then the mother is in the passive position of being delivered (Hunter 2006). The doctor is in complete control and holds the power within the institution (Rothman 1984).   The social structure of the relationships between HCP and the woman may be very different depending on each individual. The approach taken and language used can be interpreted in a variety of ways and language is seen as reflecting the social relationship being built between     34      HCPs and the labouring women and this language is consistent with societal expectations and pressures (Hunter 2006). When childbearing women receive care, this care is based on recommendations according to specific guidelines that direct care to a generalized population rather than a more individualized approach. When looking at socially mediated text, what is actually seen is women’s corporeality as a commodity and where their wishes and preferences for supportive birthing practices have been marginalized (Cahill 2001; Goodwin-Smith 2012). Along with marginalization come fear of childbearing and insecurity and these fears influence women to choose surgical birthing methods. Something is dreadfully wrong with the images and messages women are receiving. The physical reality of the birthing experience has become lost. Consequently birth has become a confusion of events resulting from a failure to understand the process of birth or failure to appreciate the meaning of birth that leads to mystification of the process. As the experience of non-medicalized birth moves farther from view, women do not believe in themselves or their bodies and the potential for the “rite of passage” in women’s development is lost (Neiterman 2012).  The medicalized picture of birthing and pregnancy follows the empirico-analytic position in science (Davis-Floyd 2001). The material realities indicate to women that the medical system is going to take care of her, with the woman having little to say about it (Howarth et al. 2012). So a woman’s voice becomes lost and she loses her ability to choose. The justification for the medicalization of childbirth, in part, lies with the belief that the female body is flawed (Martin 1987). The Enlightenment period reinforced the notion of the flawed body with the promotion of the mind and body separation, with the body becoming the object of dissection and examination (Walsh 2010). This social construction of the female pregnant body is seen to be acted on by     35      external forces that impinge on behaviour and experience (Walsh 2010). Consequently, childbirth became reductionistic and women’s bodies analogous to a machine (Davis-Floyd 2001).  The medicalized body is viewed and outcomes are predicted and are separate from process. There is no room for bias in this tradition. The empirico-analytic approach (positivism) considers singular truth claims and facts derived only from cause and effect relationships (Carr and Kemmis 1986; Denzin and Lincoln 2011; Emden 1991; Lloyd 1979). Thinking with and through the pregnant body, women come to understand their agency as embodying the foetus and subsequently all actions and thoughts are inclusive and encompass the unborn child. Today, and becoming more evident with time, the foetus is granted greater value and rights than the pregnant woman (Duden 1993). Women have been ordered by governments in both Canada and the United States to have caesarean births, fetal surgery, blood transfusions and other procedures that favour the foetus over the rights of the woman as a person (Binion 1995; Epstein 1995; Minkoff and Paltrow 2006).   Davis and Walker (2010) describe the image of women’s bodies that have emerged from medicine and modernity. An essentialist, biological approach views the body as “disconnected from the mind, spirit, and social and cultural contexts in order to be understood as an isolated object” (Davis and Walker 2010:457). The metaphor of the body as machine with parts that can fail is envisioned to explain a cause and effect functioning. Yet, from my maternal child nursing in Canada and international experiences, it is the whole woman who brings the child into the world, not merely flesh and bones (Kitzinger 1987a).       36      A Woman’s Desire for Birth Desire may be constructed not as attachment to an object/subject (Kant 1790/1914) but, rather, as the notion of possibility. In the work of Lacan (1998) desire has a very distinct meaning which is associated with absence, loss and lack. If there is a lack or an absence then there suggests space, an emptiness; desire is only possible with the speaking or articulation of that desired. Possibility hints at a potential for change combined with the notions of absence, loss or lack that allow for a feminist reading that yields a searching for a different experience and the possibility for change. Desire originates from within. Women envision what they desire for their births and wish for birthing that is fulfilling and safe, conscious and connected to family, loving and supportive. Women hope for an idyllic, pain free birth. A woman who delivers a healthy, normal child of the desired sex and, who breastfeeds well, she hopes she will love the baby and her recovery is quick and without incident.  In today’s Western culture where there is a pill for every ailment, pregnant women are requesting and “demanding” (Lippman 2004; Ryding et al. 1998) surgical intervention and they want an epidural on admission to hospital. The desire to feel no pain has rendered childbirth a frightening event (Gallagher et al. 2012; Melender and Lauri 1999). Further, the purpose of birth under this fear means that a rite of passage for women is lost and with it the loss of the sensory experience (Davis-Floyd 2001).  Choice  Choice is a hallmark of feminist thought and women, as feminists, choose to make a stand against sexism, racism, classism, sexist exploitation and oppression in order to end patriarchy (hooks 2000). Furthermore, choice is about what women want for themselves whether to be heard, to gain an education, a better life for themselves and their children, or to participate     37      in political and legal imperatives that positively work for women. However, the system works to silence women in order to keep women participating in ways that support the taken-for-granted aspects of patriarchy. In order to exercise choice women must be able to identify what they want, find their voice and have the courage to speak in order to gain change (Belenky et al. 1986). Choice for women may be witnessed in their decision to bear a child, choose an abortion or to not have children at all. For childbearing women they may now choose their care providers, depending on the availability and access to midwives and obstetricians and choice may be exercised when there is little or minimal risk. However, once in the throes of labour and particularly when the situation becomes more tenuous then choice and decision-making may be seen, by the experts, as expendable and choice may be eliminated; and actions by others, with their knowledge, power and authority, take over relieving women of their agency.  Corporeality Corporeality is the materiality and the reality of the body. Our bodies are sensory and the individual body is felt and interpreted and is on display to those who see us. It is through our bodies that we interact with and play a part in our everyday world. Nothing, “after all, is more personal than the life of the body” (Bordo 2003:17). Women’s bodies are associated with life centred on the body, which may be seen both in the beautification of one’s own body, the reproductive body and care and maintenance of the bodies of others. Bordo (2003) characterizes “culture as having a grip on the body that is constant and is an intimate fact of everyday life” (17). For the pregnant woman her body is associated and largely confined to a life centred on and concern for her body and the foetus she houses.  Conversely Bordo (2003) tells us that the body may operate as a metaphor for culture. The body is not only a text of culture, it is also, as anthropologist Bourdieu and philosopher     38      Foucault has claimed, “a practical, direct locus of social control” (Bordo 2003:165). Taught through banal activities such as table manners and toilet habits, through ritual and trivial routines, rules and practices; culture is “made body” (Bordo 2003:165). Bourdieu (1977) argues that these rituals are automatically converted into habitual activity and thus are beyond our conscious grasp through voluntary deliberate transformation. In effect, our bodies and minds are representations of our specific cultural expectations, values and desires. Each sex is directed towards a ritualized program taught to each group and when experienced through the personal lens, becomes naturalized, enacted, rationalized and agentive.  Rothman (1994) claims that in every pregnant woman, we have living proof that individuals “do not enter the world as autonomous, atomistic, isolated beings, but begin socially, begin connected” (146). Every pregnant woman we see is a walking contradiction to the segmentation of our lives; pregnancy does not permit it.  There are gaps in the literature as to how women’s experience of birthing impacts their self understanding—particularly evident in the lack of research five years post-birth. Researchers have also noted that if the mother experiences PPD, other members of the family may also experience depression (Burke 2003; Cummings and Davies 1994; Goodman et al. 2004; Letourneau et al. 2012; Miller 2002). What isn’t clear in the literature is how the experience of difficult birth affects the mother and how she creates meaning of that experience over her life. This research will explore the meaning of giving birth and create a fuller picture of women’s experiences of a difficult birth and mothering over time.  This chapter has exposed a disconnection between what has been written about women during pregnancy and birth and what women think and feel about their own embodiment. There is an increase in mechanization of birthing, such as caesarean sections, which are the highest in     39      B.C. and on the rise in Canada. Women are influenced by cultural and societal messages telling them that surgical intervention is safer than vaginal birth and that caesarean births are to be preferred. Women believe what they are told by experts and current medical practices support interventions that have become normalized through their frequency of use. However, as I will show, these interventions and medical processes work to disempower women by removing choice and dehumanizing their experiences of birthing. Following instrumental birth women are often bereft wondering what they did wrong and how things could go so badly. A side effect of these interventions, experienced by the women in this study, might be disappointment, regret, shame and trauma following their birthing experiences. For some of these women, the trauma of a difficult birthing manifested as PPD and PTSD. This research investigates the contexts that constitute a difficult birth and why women felt their births were difficult or traumatic.  The next chapter explores the methodological underpinnings of the research and how the research has been shaped by feminism through the use of critical ethnography.     40      Chapter 3 Theory and Methods This chapter explores the theoretical choices and methods that provide structure and give philosophical meaning to the research. Approaching my work with the women participants, I chose feminist informed-ethnography and critical ethnographic methods which attends to the reflexive significance of gender as a basic feature of all social life (Reinharz 1992) and reveals the realities of “women as actors” (DiIoiro 1982; Jacobsen 2009a). Using a feminist lens to explore women’s perspectives and their concerns, I bring to the surface and unpack many assumptions that constituted some of the everyday worlds of the women participants.  Feminism and feminist thought require the exploration of women’s lives from their point of view. Using feminist research strategies one is able to access women’s subjective understandings by engaging in a respectful process that enables women to uncover or surface knowledge about their lives (Belenky et al. 1986). This process involves listening closely to women’s voices, respecting their ways of being in the world and valuing their understandings of their life and its meanings. Belenky et al. emphasize the importance of women’s experience as a form of knowledge and stress the significance of subjectivities as a way of knowing (Cook and Fonow 1986; Henderson et al. 1992; hooks 1984; MacKinnon 1989; O’Shaughnessy and Krogman 2012; Stanley and Wise 1983).   Feminist epistemology and methods support data collection through the development of the life histories of childbearing women. This research aims to open up discourses about childbearing today, to make recommendations for changes that women identify as positive and supportive. In addition, this work unravels the institutional processes of modern health care to expose the reified and hegemonic medical approaches that women experience during childbirth.     41      The epistemic and research methods implemented provide a strong framework to guide and direct this feminist work and the methods are well-suited to eliciting the data I was seeking. Feminist Epistemology Feminist epistemology evolved over many decades of women who expressed feelings of exclusion from knowledge construction, seeing their own experiences, sense of self-worth and personal lives diminished and invalidated by the hegemonies in their various cultures (Hesse-Biber 2011). Feminist epistemology is both constructive and critical (Longino 1997). Critical dimensions include the “demonstration of forms of masculine bias at the heart of philosophical analyses of such topics as objectivity, reason, knowledge, and rationality” (Longino 1997:20).  These biases work to diminish women’s input hindering the advance of philosophy and science (Jiang 2005). For example, due to devaluing femininity, the knowledge that mothers have of children is not greatly appreciated (Anderson 1995:50). In general, the more a “kind of knowledge is associated with femininity, the less value it will be assigned by traditional Western epistemology” (Jiang 2005: 57). In this research I valued women’s input and their knowledge about mothering behaviours as well as their stories of birthing. Conversely, constructive dimensions include creating a legitimate place and “space for feminist ways of inquiry and identifying or defending epistemic guidelines of feminist inquiry” (Longino 1997:20). Utilizing feminist ways of inquiry through attention to women’s voices of childbearing and respecting and sharing their experiences embrace constructive dimensions. Thus, feminism provides an epistemological lens to explore childbearing and to unearth the experiences of women who have had a difficult birth and the meanings they made from that birth on their mothering.        42      Feminist epistemology guided each aspect of the work to explore women’s understandings and experiences to create new meanings about difficult births. Throughout the work I examined the gendered ways that women received care during birthing and how this impacted their mothering over time. Ethical principles were maintained through adherence to the methods and through the reflexive nature of the work.  Feminist Research  Feminist research begins with women’s own experiences and perspectives (Presser 2005) and draws upon those insights and struggles to recognize women’s lived realities, thus “unearthing subjugated knowledge” (Hesse-Biber 2011:3). Feminist researchers seek to minimize cultural hierarchies of knowledge by challenging traditional epistemic constructions while disclosing the multiple, historically significant positions women hold in relation to both the development of questions and how we go about research (Presser 2005). Feminist perspectives embrace an intentionality of transformation and empowerment of women’s legitimate voice and ethical positioning.  Feminist research embraces a sense of openness between people and of being aware of issues of vulnerability, reciprocity and mutuality (Reinharz 1992). Openness is about being present and calls for the researcher to adopt an “open discovering way of being” and to develop a “capacity to be surprised and sensitive to the unpredicted and unexpected” (Dahlberg et al. 2008:98). Being open with women is the “mark of a true willingness to listen, see, and understand. It involves respect, and certain humility toward the phenomenon, as well as sensitivity and reflexivity” (98).  Openness is gently giving purpose and being involved in an authentic, non-judgmental way with others (Finlay and Evans 2009). Reciprocity is essential for      43      the establishment of a firm working alliance and requires that there is a minimization of hierarchy between researcher and participant (Oakley 1981), the participant “is not ‘objectified’ nor placed in a passive role, but plays an active part in the research process” (Letherby 2003:83). Mutual interactions in which the researcher is open and “gives something of herself by talking about herself, answers questions when asked and perhaps feeding back some findings to respondent when writing up” (83) are also essential aspects of feminist approaches in research. During my interactions with participants I engaged in mutuality that reflected an open, respectful and attentive approach with participants.  Throughout the research I thought deeply about the women, what they said and the meanings that emerged. Reflexivity involves a process of critical reflection describing how the researcher constructed knowledge at each step of the research process (Guillemin and Gillam, 2004). This includes influences on the researcher’s production of knowledge and how these have guided and shaped the planning, conduct and also writing up the research. A reflexive researcher is one who is able to take a step back and critically evaluate her role in the research to recognize the limitations of the knowledge that is produced, leading to more rigorous research (Guillemin and Gillam 2004).  Engaging with the research and the nature of the topic I realized that my story of birth and mothering played a role in the conceptualization of the research. I was the researcher, but my experience was also part of the work. Reed-Danahay (1997) defines autoethnography as research connecting the personal to the cultural and thereby placing the self within a social context. As a maternal child educator, nurse and mother, writing about my own experiences alongside the participating women’s stories I reflected and thought about the women’s birthing experiences as well as my own also makes this work autoethnographic . As a nurse I possess “insider”     44      knowledge of the clinical setting that guides the care of birthing women as well as the acceptable and less acceptable actions of HCPs (Zaman 2008). This knowledge enhanced my understanding of the stories that women told allowing me to further delve into the women’s interpretation that added to the analysis of the data. In addition, my own understandings of the maternal child field gave me “insider” knowledge of perspective and perceptions that HCPs might consider as part of their everyday worlds and were included as part of the analysis within the narratives. Ellis et al. (2010) describe a form of reflexive/narrative autoethnography where the ethnographer studies their own experience “alongside cultural member’s lives” (5). Autoethnography is an approach that acknowledges and accommodates subjectivity, emotionality and the researchers influence on the research, rather than hiding from these matters (Adams et al. 2008). This “layering” of understandings helps to elicit political, socially-just and socially conscious acts of awareness about child birthing (Ellis et al. 2010).  Key Hallmarks of Feminist Methodology  Current feminist thinking includes a diversified approach to inquiry. Amid the multiple and complex ways to conduct research, Olesen (2011) has emphasized that voice, ethics, reflexivity and transformation are key to feminist methods and I consider them briefly below.  Voice The emphasis on voice in research is grounded in feminist methodology (Millman and Kanter 1979). Voice reflects the meanings inscribed in experience, as interests and focus are revealed in what a woman says. Historically, women’s voices have been silenced and not taken seriously (Gilligan 1982; Lloyd 1979). Problematizing women’s embodied realities is an act of consciousness-raising. Once they have developed their own understanding of their position(s) in the world, women’s voices arise from the practical, experiential and pragmatic everyday     45      experiences that reflect a gendered lens through which to view their cultural positions (Bordo 2003). By giving voice to their experience women engage in sharing meaning. Women who articulate their own experiences of birth offer an opportunity to uncover and interrogate birthing and mothering experiences though “story telling.” In narrating their stories, women speak with their own voice and from their own situation; their subjectivities and societal positioning shape their understandings and knowledges about the world in which they live. As women’s contexts differ, so too will their subjectivities and their experiences, to reveal different knowledges and meanings imbued with alternate understandings. Women’s knowledge of their subjectivities and experiences may be shared through speaking aloud through their voice and the notion of voice is inherently political. Knowledge is understood as power and those individuals with knowledge have socio-economic and political power to change things if they choose. Cultural practices, language discourses and social relationships reveal privileged often hegemonic perspectives, including issues of social justice (Bordo 2003; Chodorow 1978: Harding 1991; Ho 2007; Spender 1987). Rather than seeing ourselves in retreat or defeat, Batliwala (2007) encourages women to recognize that we are witnessing a historical and dialectic process, where our voices and claims have been ritualized as a means of neutralizing or pushing back the changes in power that were sought along both gender and social hierarchies. There are three tasks of reclaiming, reframing and resistance required to bring a new clarity of voice, vision and to invigorate strategies on the part of feminists (Batliwala 2007). Feminist research is a means of addressing those tasks. My conversations with women have helped to unpick their understanding of their difficult births and mothering, to reconceptualise their experiences by allowing for emerging empowerment and transformation in thinking about the birthing event and the impact over each participant woman’s     46      life. The interviews and conversations opened up a space for women to look at, reconfigure,   reframe and voice their own experiences in order to help other childbearing women prepare for birthing with the stories, knowledge and wisdom of experienced mothers. Sharing birthing stories with an active and interested listener women can work to empower themselves through validation of their experiences.     Ethics  Human agency is guided by an individual’s ethical position (Rallis and Rossman 2010). In this section I briefly discuss traditional health care views on ethics, including non-maleficence, respect for human dignity, veracity and fidelity in relation to client care as outlined by professional and legal parameters of health care professionals in Canada (British Columbia Medical Association 1995; British Columbia Midwifery Association 2004; Canadian Nursing Association 2008).  The time-honoured ethical principle of non-maleficence or “do no harm” is considered the highest duty of professional care providers. A basic consideration in care giving and in virtually all professional codes of conduct is first, do no harm (CNA 2008). This raises the question of how one knows that their actions are causing harm, without knowing the lived experience of that person. To bear witness, or not, (Levinas 1979) constitutes a “rhythmical interchange,” a way that health care provider can co-participate in the lives of the person they are serving (Milton and Cody 2001:290). To refuse to bear witness through a person’s time of profound vulnerability and pain is to choose a stance likely experienced by those persons as injury and insult (Milton and Cody 2001).  The respect for human dignity by professional governing bodies forbids any restriction on care giving related to the characteristics of clients, their socioeconomic status, health problems,     47      or environment. All HCPs must respect human dignity, the uniqueness of the client and their situation. The principle of veracity is another foundational ethic of health professionals. Care providers are bound to provide honesty and truth to the client, unless doing so will cause harm to the client. Withholding veracity is a form of “paternalism, which holds that one should decide what is best for the client and whether truthfulness will serve that end” (Milton and Cody 2001:290). There is an implicit assumption that care providers, with their scientific knowledge, somehow have a closer understanding of truth than the person receiving care. However, when   care providers focus on the individual’s experience, there can be little pretense that they know better than the client. Being faithful to the client’s desires, hopes and dreams from their perspective and by honouring human dignity, brings a sense of fidelity, which must be central to the integrity of professional philosophy, actions and outcomes, for a client-centred approach  to health care delivery (291),  The development of rapport by establishing respect and trust between people facilitates a relational ethical stance (Gadow 1985, 1999). Such an approach in feminist research thus   addresses issues of relationship, social justice, disparities in power, and the legitimacy of the experience of the other. Feminist ethics also addresses how research methods are constructed, including valuing difference, acknowledging emotions and subjectivities, as well as addressing confidentiality, privacy and avoiding harm (Preissle 2007). Finally, feminist ethics assumes a “caring reflexivity” (Rallis and Rossman 2010), that is, intentionality for social change that has practical implications for the improvement of women’s lives (Harding and Norberg 2005). Reflexivity and Transformation Over the past few decades, reflective inquiry has been used as a method for investigating and resolving problems enabling HCPs to direct their observations and thought to improving     48      practice (Dewey 1933). Reflexive methods is a means whereby the process undertaken in research are made transparent and used as part of the data (Bulpitt and Martin 2010). Opting for a reflexive approach in the research requires understandings of how a researcher’s social background, status, personal assumptions and ways of being in the world affect and influences the researcher and the research project (Hesse-Biber 2011; Rice and Ezzy 1999). Enacting a reflexive approach to research encourages feminist researchers to examine the temporalities and connections of everyday experiences and places these experiences at the centre of enquiry enables exploration of “whose knowledges are dominant, where and how was the knowledge obtained, by whom, from whom, and for what purposes” (Olesen 2011:129).  Carolan (2003) argues that reflexivity is an inter-subjective experience of connection, a dialectical process between self and other therefore, the role of researcher is subject to the same critical analysis and scrutiny as the research itself. Reflexivity is not a single event but a process that assists in dealing with the ethical aspects of research, as well as guiding the research and researcher. In particular, the researcher’s personal experiences, characterized by self-critique and self-appraisal, are integral to the actual research (Koch and Harrington 1998; Reinharz 1992). By paying attention to the specific ways in which personal agendas affect the research at all points in the research process—from the identification of the research problem, to the theoretical approach and methods chosen to access the data, to how the research findings are analyzed and interpreted. Hertz (1997) notes that the reflexive researcher does not merely report the facts of the research but also actively constructs interpretations, such as, “what do I know?” At the same time the researcher questions their own interpretations by asking themselves, “how do I know what I know?” (Hertz 1997). MacKinnnon (1989) advocates the use of consciousness-raising by asking questions of agency through problematizing one’s social reality and that it is possible to see     49      things differently. Through this hegemonic process transformation of new understandings can lead to emancipation. Feminist research strategies are designed to be respectful and ethical to both participant and researcher. Built into the methods used in this project is a sense of reflexivity, which means that the investigator is both the instrument of research and the researcher, and therefore, part of the research design. Feminist research offers the opportunity to engage respectfully in an exploration of women’s intimate worlds without exploitation. In this research project, I and my respondents engaged in consciousness-raising designed to support empowerment of the interiorized embodiment of women and mothering. Feminist epistemology and methods are thus well-suited for an exploration of the meaning women make of their childbearing experiences and of their mothering after a difficult birth. Moreover, a critical perspective ensured the empowerment and emancipatory elements for change underpinned the study.  By engaging in reflexivity, multiple perspectives are brought to bear to better understand the impact over time of a difficult birth on mothering. Gender as a category serves to unravel the many social and structural texts that have bearing on creating a birthing experience. Exploring women’s subjectivity politicizes personal experience and, in doing so, facilitates greater awareness and understanding of the cultural conditions in which the women participants gave birth and mothered their child. It is in these moments that the transformative intent of feminist research becomes apparent through the potential for bettering women’s lives. Hence, women’s experience as knowledge can be theorized. I searched my own understandings to identify where I came to specific theories in action (Argyris and Schon 1978; Argyris 1993; Mezirow 1990), how I knew and how these knowledges influenced my practice and the research process.     50      Experience is constituted in language and language is an assortment of ways of interpreting diverse versions of experience, women’s ambiguities, authenticities and subjectivities can be expressed, in part, through words. Language acts to position women in their realities in particular ways that in turn are conveyed through story as meaning.   Delving into issues women face through storytelling, which has the effect of sharing their embodied knowledges, has the power to expose new awareness and the potential for creating change (Gluck and Patai 1991; Grosz 1994). However, cultural and societal pressures impinge on women in other ways, shaping expectations placed on them in their everyday lives. For many women, enculturated expectations have served as an oppressive regime of truth, actively working against them to subjugate their understandings and valorize ideologies that undermine their realities. Feminist methods help inform participants’ embodied worlds that aim to interrogate the ways in which oppressed groups can be transformed and empowered, particularly by grappling with the power of resistance to dominant ideologies and to the colonizing gaze and agency of dominant groups. Engaging in a form of feminist praxis problematizes and explores the taken for granted beliefs and practices imbued with power and authority with the intention to transform understandings and create meanings.  Meaning Making Making meaning, according to Durkheim, is about organizing and constructing experiences we have as humans and assigning merit and learning based on our social world (Dobbin 2009). The organization of information is a fundamental way to make meaning (Dobbin 2009) and making meaning is necessary for humans and constitutes a powerful motivation for living (Frankl 1973).      51      Meaning making has implications for childbearing women and becomes an important element to understand how, from their experiences of birth, women make meaning from the events that occur (Wickramasinghe 2010). The most significant new relationship for the women is the one with the child and has the power to change women’s priorities in life (Prinds et al. 2014).  Becoming a mother is a momentous life experience and within this transition to motherhood existential consideration regarding the meaning of life are reinvigorated (Prinds et al. 2014). The relationship to the child is a fearful confrontation of the potential loss of the child and a heightened awareness of the potential for aloneness and failure. While motherhood is constructed as a joyful event, in reality, this view diminishes the process of the birth experience and negates the confrontation with human fragility (Choi et al. 2005; Prinds et al. 2014).  Mezirow and associates (1990) have identified how people structure meaning. First, there are “meaning schemes” or sets of related and customary expectations or relationship categories often referred to as cause and effect. For example, we anticipate that walking will get us further to our destination or turning the key will open the door. Meaning schemes are seen, in this way, as rules for interpreting our lives. The second, “meaning perspectives,” are made up of higher order beliefs and orientations. Examples of teacher-student, mother-child and other familiar role relationships establish meaning perspectives involving customary expectations familiar to everyone. Further, meaning perspectives refer to the “structures of assumption within which new experience is assimilated and transformed by one’s past experience during the process of interpretation” (2). This process of incorporating new experiences involves the application of habits of expectations to objects or events to form an interpretation and then take action. Usually acquired through enculturation, meaning perspectives involve “ways of understanding and using knowledge and ways of dealing with feelings about oneself” (3). Often the context of an     52      emotional event will become reinforced and embedded in our memory and perspectives. Ideas of ourselves and our sense of identity are tied up in previous experiences and the meanings we made those past experiences. Over time, experience strengthens our structures of “meaning by reinforcing our expectation of how things are supposed to be” (Mezirow 1990:4), thereby making meaning from an event.  Wickramasinghe (2010) speaks of meaning making as a compounded metaphor that can be applied in various ways to research methods but can also be applied to meaning making at an individual level. Wickramasinghe’s considerations of meaning making theory is useful to appreciate women’s processes for understanding the experience of difficult birth and the meanings they make of that experience. Meaning making involves reading the multiple connotations of an event, including the interpretation of realities and making personal sense of “experiences and of assimilation at an individual psychological level” (8). For the women in this study, the meaning they make from their birth experience shapes their understandings and how they take these experiences into their lives. In this way, women make sense of their birthing experiences through an interpretation of their material realities. Ethnography  Ethnographic research is a way of studying and describing a people to discover and investigate social and cultural patterns and meanings (Angrosino 2007; Street 2014; Van Maanen 2011; Wolcott 2005). Ethnographic methods are ways to “uncover meanings in everyday practice in such a way that they [meanings] are not destroyed, distorted, decontextualized, trivialized or sentimentalized” (Benner 1985:6). Best known as an anthropological method, ethnography is also successfully used by nurse researchers in contemporary research (Aamodt 1982; Baillie 1995; Cruz and Higginbottom 2013; Leininger 1985; Manias and Street 2001).      53      Ethnographers uncover what people do and why, before assigning meaning to people’s agency. Geertz (1973) claims the ethnographer “inscribes social discourse” (19) by writing it down and the ethnographer encounters “a multiplicity of complex conceptual structures, many of them superimposed upon or knotted into one another, which are at once strange, irregular and inexplicit and which he [sic] must contrive somehow first to grasp, then to render” (10) understandable to the reader. This interwoven configuration of concepts and societal structures is, particularly during the transformation of woman to mother, through a complex array of experiences that require investigation.  There are four important hallmarks that guide ethnography and the generation of theory. Ethnography is conducted locally and resultant data is copious, dense and detailed (Geertz 1973). The data provide a new understanding that is holistic, discloses the complexity of human experience and uncovers meaning behind actions. Geertz (1973:7) uses the term “thick description” to describe the type of rich, complex data collected while doing ethnographic research. Doing ethnography “is like trying to read (in the sense of construct a reading of) a manuscript—foreign, faded, full of ellipses, incoherencies, suspicious emendations, and tendentious commentaries, but written not in conventionalized graphs of sound but in transient examples of shaped behaviour” (10). Thick description is a means of bringing to the surface the complexities, contexts, and situatedness of women’s lives, and taking notice of the nuances of human nature and personality, to respectfully expose dimensions of meaning grounded in the everyday realities. Ethnographic data collection that enables thick description, through investigation into another person’s world and feminist research methods are well suited to a study of women’s birth experiences.      54      Feminist research revolves around the need to know and understand the nature of the oppression women sustain as women. Using ethnography allows a holistic approach to the study of women and to value their storytelling and meaning made from childbirth. Ethnography, particularly critical ethnography, allows for the exploration of women’s experiences from positions variously reflecting women’s perspectives (Harding 1986). Critical Ethnography  Hammersley (1992:96) describe critical ethnography as “an ‘appropriation’ and ‘reconstruction’ of conventional ethnography so as to transform it into a project concerned with bringing about human emancipation.” To that end it values the history of the research setting, recognizes the political dimensions of the collaborative researcher–participant undertaking (Hammersley 1992) and offers the potential to both investigate and affect the social and political aspects of the research participants (Foley and Valenzuela 2005) who are central to the process of doing collaborative research. Critical ethnographic research provides a forum for consciousness-raising from which nurses and clients can work together to understand and restructure clinical practices (Foley and Valenzuela 2005). For a woman who experienced a difficult birth, consciousness-raising helps to identify those factors that were within her control and outside her control. What makes this research project a critical feminist ethnography is that it brings a critical perspective to the position of the researcher and the participants. In particular, critical ethnography asks “in whose interests does the research serve?” and problematizes economic, cultural and social worlds and their taken-for-granted aspects, to see what is at stake and for whom. Moreover, a critical perspective problematizes discourses, practices, and social relationships in ways that illuminate hegemonies and how they become reified in the everyday     55      world. A critical feminist ethnography thus helps to unravel the social aspects of our world, but it also investigates the nature of oppression and our subjectivities. Methods Throughout the interviews I used a cyclical approach to the development of my inquiry. I formulated questions, asked a participant to share her story and then checked to see if I had covered all my questions. I also reflected on my own assumptions throughout the research. I   reflected on my own personal and professional understandings and knowledge of birthing and its processes in the hospital setting. I examined my thoughts and questions about the stories and I analyzed the process by which my interpretation was made throughout the research and how the course of description was achieved (Fox 1993). Such reflexivity is an extension of communication into the deeper domains of human experience (Freshwater and Rolfe 2001) shedding light on my respondent women and the performativity of motherhood (Butler 1988). Moreover, I engaged each woman with a commitment to reciprocity through mutual sharing of understandings with sincerity and honesty. Where possible, I engaged in mutuality and authenticity through joint decision-making, such as how conversations should proceed and by being flexible with schedules, family and commitments. To access women’s stories, I used elements of ethnographic methods to capture life history through narrative and to uncover memories and meaning in artifacts (such as photographs) which the women shared with me. My ethnographic method included the feminist epistemological hallmarks of reflexivity, voice, ethics and transformation. In addition to paying attention to ethical concerns, the participating women were informed of all aspects of this study—from recruitment procedures, ethical considerations, addressing data collection and data analysis to the drawing of conclusions.     56      In my method, I adopted Wolcott’s (2005) trilogy of research methods: experiencing, enquiring and examining. Instead of experiencing the women’s lives through researcher observation (Wolcott 2005) I experienced their lives through their stories (Lyotard 1984). Enquiring or, asking questions during the interview (Wolcott 2005), was an active part of the research as I enquired of participants what was going on and probed to discover their experiences of birthing. The last aspect involves examining artifacts and mementos, such as photographs, toys and memorabilia, which served to trigger memories about their mothering over time. These steps, along with keeping field notes and journaling, formed the basis of data collection for my study.  Reflexivity influences a researcher’s production of knowledge and guides and shapes the planning, conduct, analysis and writing of the research. A reflexive researcher takes a step back to critically evaluate her own role in the research. In addition, a reflexive stance also recognizes the limitations of the knowledge that is produced (Guillemin and Gilliam 2004). Given the nature of the research question, the feminist perspective taken, the position of the researcher and of the participating women, this questioning became an important consideration given the fluidity of power relationships built into research (Stanley and Wise 1983). I remained aware of reciprocity, mutuality and issues of vulnerability (Reinharz 1992) and reflected on the authenticity of human issues I encountered, thus legitimizing and grounding the work and ensuring research rigour (Meleis 1996).  Aims of the Research This research is designed to investigate the impact of a difficult birth on a woman and on her perception of her own mothering. I wanted to investigate difficult birth experiences to determine if over time, this experience affected how women made meaning of their experience,     57      and their relationships with children and family members. Over the course of my research, I conducted three interviews with each of the 12 women (see Appendix - C for a list of starter questions). The open-ended interview approach enabled the women to share with me their individual stories, from which I was able to identify common threads and, using a reflexive approach, dig deeper and develop subsequent questions to further probe their difficult births. Synthesizing the data resulted in the establishment of six analytic categories: enforced silence: bullying (including being ignored or made to feel stupid); neglect; isolation; ‘projected stigma;’ and ethical issues implicated in biomedical birthing practice. Artifacts Images and objects help to shape memories. Photographs, for example, freeze moments in time and provide a means of reflecting on the past. Images sharpen memories from exact moments, bringing forth recollections such as who was in the room and what one’s private thoughts were. Thus, I asked women to share pictures of their baby, baby books and other mementos as part of their interaction with me (see Appendix B – Consent Form for Artifacts). These artifacts provided a rich and fuller picture of the women’s birthing experience and to learn how the women related to the mementos linking the past to the present in their creation of meaning. The sharing of personal artifacts encouraged further discussion thus incorporating these discussions and mementos into the interview process and the research itself. A baby’s teddy bear, blanket, photograph or toys are reminder of that childhood time in a family’s life and helped establish context for the women’s stories.      58      Ethnography: Life History through Stories or Narratives Life history is a method used within ethnography to indicate a narrative study, either oral or written, (Connelly and Clandinin 1990; Holloway and Freshwater 2007; Polkinghorne 1995) of an extensive autobiography or biography (Chase 2005). According to Chase, life history may be presented as a short topic story or a narrative of one’s entire life, from birth to the present or as an extended story about “a significant aspect of one’s life such as schooling, work, marriage, divorce, childbirth, an illness, a trauma” (652). A life history may revolve around an epiphanal event (Denzin 1989) or a turning point in one’s life (McAdams et al. 2001). Birth particularly one that is difficult, can be said to be an epiphanal moment and is a turning point for substantive changes in a woman’s life. Collecting life history narratives supports my intent to interview women about their mothering starting from their childbirth experiences (Angrosino 2007). A life history approach links experiences or actions and the theoretical with the personal (Mandelbaum 1973). Capturing a life history usually involves multiple interviews over an extended period of time (Hagemaster 1992; Haglund 2004). Based on starter questions in an interview format (see Appendix B), I used semi-structured in-depth interviews over three meetings to explore each woman’s birthing story and history of mothering. Stories of relationships and context added to the richness of the conversation. I found myself in a virtual space, travelling with the women as they shared their path of lived experience through their births. Life History: Hearing Women’s Stories through Thick Description Stories or narratives help people make sense of their experience (e.g. Bochner, Ellis and Tillmann-Healy 1997). With personal knowledge there is an opportunity to reclaim and reframe one’s previously “inscriptive” exteriority (Grosz 1993) and to seek a more accurate, reflexive     59      and “true” rendition of one’s interiorized, intimate world. Thick description is a means of bringing to the surface the complexities, contexts and situatedness of women’s lives and taking notice of the nuances of human nature and personality to expose dimensions grounded in their everyday world (Geertz 1973). The potential for data collection that includes thick description and feminist research methods is well-suited to a study of women’s birth experiences. The research offers the opportunity to engage in a non-exploitive and respectful exploration of women’s intimate worlds. All participants engaged in consciousness-raising designed to support empowerment of the interiorized embodiment of women and mothering. Recruitment and Working with Participants Women were recruited to the study through advertisements (see Appendix D) posted in various communities, as well as through word of mouth or, the “snowball” technique (Babbie 2012). I provided a small package for each participant that included information describing the study (for a list of enclosures see Appendix G), a letter of introduction, consent forms (Baker, Lavender and Tincello 2005) and my contact information (see Appendix F for letter, Appendix E for consent form and Appendix I for contact information), as well as a list of counselling services in their geographic area (see Appendix K). Initial Contact with Participating Women  After a woman connected with me, I set a time to meet with her in a setting of her choice such as in her home, a coffee shop, restaurant or my office. In our preliminary meeting, I described the study and my intention for three audio-taped interviews, other data collection methods and the time the study required. Subsequent interviews were held in a variety of settings that worked for them and the process. Coffee shops, outdoors and restaurants were problematic due to background noise, which impaired the audio component making it difficult to decipher,     60      and we avoided these locations for locations that were quieter. All the women who came forward elected to participate in the research after our initial discussion and each woman signed the consent to participate prior to the first interview.  Each time we met, I reviewed consent. I gave a list of starter questions to the women in advance to ensure they knew the types of questions I would ask, as well as the potential length of time involved (Forbat and Henderson 2005). In addition to the questions posed women shared other details about their lives (background and context). Most women shed a tear or wept at the first interview; yet, reminiscing did not bring up negative latent issues as I thought they might. Some tears surrounding birth, such as when love began and other heartfelt moments, also brought tears of recalled joy and happiness.  The participants were all English-speaking women over 19 years of age who had experienced a difficult birth at least two years ago as a minimum period in order to track the effects of a difficult birth over time. The woman herself defined her birth as difficult and that the birthing experience affected her mothering. Participants were not required to have a medical examination or confirmation as to any “medical diagnosis” of a difficult birth. There was no limit to the length of time since a difficult birth occurred, which allowed women over 19 years of age to participate. Women recently diagnosed or currently experiencing symptoms and/or being treated for posttraumatic stress disorder (PTSD) were excluded. My goal was to understand the impact of a difficult birth and how women experienced mothering over time (Lindseth and Norberg 2004; Waldenstrom 2004). In order to investigate the question of the impact of a difficult birth on mothering, I conducted life history interviews with 12 women over a period of one year (Easton et al. 2000). Delving into the interiority of women’s experiences, I paid attention to the women’s meaning-making (Grosz 1993).      61      The Twelve Women I interviewed women whose difficult births occurred from three to 33 years ago and who thus represented a broad range of ages, differing cultural times, health care practices and aspects of technical birth (See Table 1 for a list of demographics). Of the 12 women, ten said their first birth was difficult, one identified her second birth as difficult and another identified her third birth. All were English-speaking Canadians, representing many provinces, with the exception of the east coast of Canada. While most were Caucasian, one woman was of First Nations heritage. Three were nurse educators, one was a practicing maternal child nurse and one a newly graduated practical nurse. Three women stated their own mothers were registered nurses and one woman’s father was a doctor. Eight of the women had post-secondary education at the time of their births. Culturally eight of the women can be assumed as privileged (Turcotte 2011) due to their educated level and assumed socio-economic status. Four women did not have higher education at the time they gave birth. Regardless of educational status, all the women in this study experienced what they describe as a difficult birth. Education offers little protection from the effects of birthing on mothering, although several of the women were not deemed as privileged and were regarded with disrespect.  Three of the participants were nurses when they gave birth. Their education and knowledge of hospital birthing and awareness of procedures may have helped to provide a deeper articulation of their experience and the difficulty they endured; however, their understandings did nothing to ameliorate their suffering. Two other participants became nurses after their difficult births and their reflections about their births were then read through nursing knowledge acquired after their births. One woman who related her naivité at the time of her birth and was shocked during her education on neonatal resuscitation with further realization of the       62      Table 3.1 Women’s Birth Demographics Name Age Year Since Birth Pregnancy Type of Birth Medical Complications Mental health and counselling Amber Early thirties 12  First  Suction and Forceps Epidural C-Difficile Third degree tear  Barbara Late twenties 15  First  Forceps Epidural Third degree tear Depression and counselling Carol Late twenties 20  First  Cesarean Section Preterm birth at 30 weeks Kink in ureter Hospitalized for several weeks prior to birth  Diana Late teen 12  First  Forceps Epidural Post-partum hemorrhage To O.R. for repair of third degree tear and tear of cervix   Eileen Early thirties 13  First  Vaginal birth Prolonged healing time  Francis Thirty 8  First  Attempted forceps, then Cesarean Section Infected incision for a year   Depression and counselling Gillian Late teen 34  First  Cesarean Section General Anaesthetic Pelvic infection (sepsis) Depression and counselling Hillary Late twenties 14  First  Vaginal birth Preterm birth at 30 weeks Depression and counselling Isabelle Mid thirties 33  Third  Vaginal birth Preterm birth at 31 weeks Ruptured appendix PPD Jennifer Thirty 5  First  Cesarean Section Epidural Breech presentation Brain tumor  PPD and counselling Karen Late twenties 17  Second  Vaginal birth Induced birth at 38 weeks Kink in ureter  Lyanne Early thirties 13  First  Cesarean Section Preterm birth at 30 weeks  Intrauterine growth restriction and oligohydramnios PPD, PTSD and counselling     63      danger she and her foetus were in at delivery. One of the women was lesbian and her hospital experience was affected by discrimination whilst her child was in the Special Care Nursery. The woman with First Nation’s heritage stated she over-heard racial epithets about another woman whilst hospitalized.  Data Collection All interviews were digitally-recorded, transcribed verbatim by myself or a transcriptionist, then checked against the tape for accuracy. Transcripts were then returned to each woman so she could verify and clarify her contribution prior to the next meeting. On each subsequent interview, I clarified my process and asked the participants to share any thoughts that may have surfaced since our previous interview. Corrections and additions were then made to the description of her experiences. Participants validated, embellished or deepened previous conversations, adding to the validity of the research. If I forgot to ask specific questions I sent the women messages via email and received prompt responses. I gave open invitations for women to contact me through email or telephone with any additional thoughts and recollections and several used email to provide clarifying details they wanted me to know. As a nurse I am skilled at observation and in noting moments of sadness, emotion and discomfort. I observed details of the participant’s demeanour, affect and sense of agency as thick descriptions (Geertz 1973). This added context to the women’s experience but I also noted my own feelings, questioned my reaction and explored my own difficult birth experience. These latter notations helped to develop my own reflexive voice within these complex layered dimensions of the women’s realities.     64      Methods of Data Analysis Data collection and analysis occurred simultaneously as well as through ongoing reflection (Glaser and Strauss 1967). I had initially planned to use N-Vivo® to organize my data but found that reading the text and the use of pen and paper as the research unfolded was a more effective way to work with the data as it grew in depth and breadth. To identify themes, I used ethnographic coding, categorizing and clustering of themes to analyze data as the stories unfolded (Morse and Field 1995). Reading and re-reading of transcripts for clarification, context and content was ongoing, until I could hear each participant’s words and their voices in my mind. I worked with the data and wrote their stories as a narrative text (Connelly and Clandinin 1990; Holloway and Freshwater 2007; Smith and Watson 2010). To ensure their stories were accurate, I went back and forth between the transcripts and the narrative to confirm that I captured the woman’s situation as she described it. I clustered the women’s stories and narratives into a number of emerging themes. Organizing the work into themes took several attempts to uncover how best to present their stories in a respectful, compelling and thoughtful way. After the initial analysis of individual stories, I tried to make sense of their experiences by mapping concepts, which helped to create another set of meanings that emerged from the interviews. I arranged each woman’s interview data in such a way that I could then see how many experiences were similar or unique to gain an overall sense of the birth stories. I highlighted information such as years since birth occurred, birth complications, interventions and other factors to exemplify each story in relation to the other participants. I also grouped their narrative responses to the initial questions to gain an overview of experiences. This provided multiple contexts and gave both historical and a contemporary sense to the interpretation.     65      I used the knowledge and information gained from the two previous interviews to develop the final interview questions, which extended my understanding of their experience. In order to improve birthing experiences for other women, I asked participants for recommendations they would offer health care providers. I enquired how the participant’s experience of a difficult birth affected their mothering over time and affected them as they have matured as women. Rigour  Traditional approaches, such as the empirico-analytic tradition, are inappropriate to gauge the rigour of this research (Denzin and Lincoln 2011; Koch 2006; Koch and Harrington 1998; Lather 1991; Rolfe 2006; Van Maanen 2011). Instead, various approaches to exploring the rigour of qualitative research have been described notably by Beck (1993), Beck et al. (1994) and Sandelowski (1993). Thus, credibility in this study is created through the description of sequential steps that provided the map within the study, recording the process and the methods followed. “Truth” value is obtained from the discovery of human experiences as they are lived and perceived by participants and these realities are multiple. I value the women’s knowledges as both legitimate and subjective and took seriously the women’s contributions and validations of their meaning-making. Repeated interviews, observations and use of artifacts ensured that multiple methods of data collection allowed for questions to be explored and clarified and to determine the congruence of the results within the study (Morse and Field 1995).  Grappling with how to “measure” rigour within qualitative work is “a futile task” since all research is on a continuum and each study is individual and cannot be measured against prescribed frameworks and criteria (Rolfe 2006:303). However, Rolfe does say that all published research reports should include a reflexive research diary. For a study on women and their     66      experience of mothering following a difficult birth, a reflexive approach is a foundational feminist method. Lather’s (1993) conceptualization of transgressive validity is “the most completely worked out feminist model” (Olesen 2011:136) offering a feminist emancipatory stance. Lather (1993) argues for four frameworks in examining validity: ironic, neo-pragmatic, rhizomatic and situated. I chose situated validity in particular, Lather’s concepts of situated validity “to embody a situated, partial, positioned or explicit tentativeness” (686) of the work for others to read. Situatedness and partialities, as a measure of rigour, are also reflective of those aspects that women experience in their everyday lives. Situated validity also constructs authority through practices of engagement and reflexivity, which have been included in the design of each aspect of this research. Validity of this nature creates a questioning text that is simultaneously bounded and unbounded, closed and opened.  Thus, the women’s stories are bound by their experiences and description but are unbound when others find resonance with the narratives of the women’s realities. Situated validity also brings together the concepts of ethics and epistemology. Within this work, the strong ethical principles reflected in relational practice and knowledge construction are part of the feminist research foundation to transform the social position of women. The authenticity of the women’s stories may be recognized by others who may have experienced or known of similar situations in their own lives or that of other women. This resonance with women’s experiences acts to support validity (Lather 1991). The small number of participants represents individuals who have experienced a difficult birth; however, their stories provided rich data to explore the impact of difficult birth on the life of a woman. The applicability of findings rests with readers as they read and interpret the stories and acknowledge women’s experiences. The narratives may resonate for the reader, adding to an     67      understanding of women’s experiences and the applicability of the study. The intent is to offer the women’s stories to shine light on the impact their difficult birth had on their mothering. It is my intention to illuminate the participants’ understandings so the reader obtains glimpses of the women’s experiences, thus raising awareness of the longer term impact of a difficult birth on mothering. By “creating the evocative, true-to-life and meaningful portraits, stories and landscapes of human experience … [is to] constitute the best test of rigor in qualitative work” (Sandelowski 1993:1). Furthermore, the kinship between art and science and qualitative research “bridges these realms of meaning” (3). Rigour is achieved through the consistent application of the research approach, where we seek meaning in the human experience, in this instance, of mothers after a difficult birth (Meleis 1996). This chapter has provided a brief overview of the theory and methods used in this research. The philosophical approach of ethnography, feminism/feminist research epistemologies and ethical concerns guide each aspect of the study. The next chapter will begin with the narratives of the participating women and how their lives have been changed by their experience of a difficult birth.       68      Chapter 4 Women’s Stories of Childbirth In this chapter I provide narratives of the birthing experience that led the women participants to define their births as difficult (Holloway and Freshwater 2007). What made the births difficult included not being believed, listened to or included in decision making, not being respected and treated with distain and being left alone. Other women experienced urgent medical situations that involved themselves and their unborn child and the potential injury or loss of the newborn. I then present the women’s views on how they think their difficult birth affected their mothering over time. Women in this study talked at length about the difficulty they experienced with the births of their children, their relationships with them today and the lasting effects of these difficult birthing experiences on their mothering over time. In addition to physical, corporeal and emotional scars, several of the women had iatrogenic wounds that took many months to heal.  Each woman’s narrative provides some background information to assist in developing an understanding of the differing contexts for the women giving birth and how their mothering was affected over time.  Of the 12 women in the study, three (e.g. Isabelle, Jennifer, Lyanne) were diagnosed by a physician with postpartum depression (PPD) and were treated with antidepressants. Isabelle had experienced PPD with her previous two births but she felt the third birth was the worst. Jennifer experienced PPD after she delivered her daughter, who died of a rare brain cancer at three months of age. She sought help and counselling for her grieving and loss, work that is on-going. Lyanne also suffered from what was labeled posttraumatic stress disorder (PTSD) and was hospitalized after the birth. Three other women sought counselling for depression following their     69      difficult birth experiences and during the years after (e.g. Francis, Gillian and Hillary). Most of these women have other children. For two women (e.g. Diana, Eileen), the difficult birth experiences resulted in that baby being their only child. Three women suffered prolonged recoveries and protracted healing times following their difficult birth experiences (e.g. Amber, Diana and Eileen).  The partners of Amber and Eileen provided support and care for several months during the postpartum period. Both women spoke of a deep connection to their children that developed over this period. This situation worked to draw the couples closer and both women were thankful for their partners’ attention and care. Amber and Eileen spoke of the close relationship their husbands have with these children, from being so hands-on in the early days following birth.  Amber: Narrative of Difficult Birth  Amber, a nurse, in her early thirties, was pregnant in 2004 with her first child. She prepared for birth through reading and attending prenatal classes. At full term, Amber began labour at 6 a.m. She was excited about the imminent birth and at 9:30 a.m. she went to the hospital. Amber was dilated two to three centimeters. “I didn’t have a birth plan. I thought, ‘It is my first child, and we’ll see how I am going to react to it.’” She tried going into the bathtub but as the pain intensified she decided to have an epidural. It was a Sunday and a quiet day in the labour unit.  By the afternoon the physician ruptured her membranes to progress the labour. “I think the doctor wanted to deliver the baby. We don’t know for sure but we had a feeling she was going out and wanted to get the baby delivered.” When it came time to push Amber couldn’t feel anything because her sensation was entirely blocked from the epidural. “They decided it was     70      time for me to push and I wasn’t feeling anything so I just went along with it.”  They had to turn the baby and since the baby wasn’t descending the physician tried suction and then used forceps.  Amber relates that the baby’s Apgar scores were OK and she was “cone-headed but fine.”  As usual with forceps deliveries, Amber had an episiotomy and she also suffered a tear into her anus (third-degree tear). Her voice shaky with emotion, Amber told me, “It wasn’t until they got Avril out that I realized how difficult that was.” It was at this point, Amber felt that the birth was difficult and that she suffered. Amber said that immediately following the repair of her perineum and tear, Amber was in a lot of pain. After several days she was discharged from the hospital but the pain in her perineum increased. On day five she went to the doctor who diagnosed an infection of the episiotomy and placed her on antibiotics. She then developed C-difficile, which causes severe diarrhea when normal gut bacteria are killed by antibiotics. Amber recalled she, “was very sick and breastfeeding.” Amber’s husband, Allan, took her to emergency where she was given intravenous fluids and more antibiotics, “The whole process went on for so long it took about 6 months for the stitches and the scarring to heal. I was surprised I had more children after that.” Impact of a Difficult Birth on Mothering  When Amber began to speak of her difficult birth she became emotional. She spoke about her life context and experience of becoming a mother. Amber described how her mothering affected the connection with her first child and her husband, making their relationships deeper because he was there to help her at a time when she was extremely vulnerable. The difficult birth brought her closer to her child because of the sense of risk involved at the birth and what they had gone through together the weeks following. I asked Amber how the difficult birth affected her mothering: “I think it’s that change of control. Not     71      having control all the time; but the other piece of being supportive and an advocate for her.” Feeling as though she had little or no voice to speak up for herself and her child at the birth, Amber identified that today she is determined in her advocacy; “so when April [her second child was born] I didn’t let things happen as they did. Then I had more of a voice. You reflect and you learn.”   Barbara: Narrative of Difficult Birth Barbara recalls the “actual delivery [of her first child] was about 29 hours, so for many reasons it was a difficult birth.” The medical aspects of her birth made it difficult but so, too, did the fragility of her relationship with her partner and family. She had married a man from South America, whom she described as very family-centred and wanted his family present for the birth. His mother and brother came to Canada and were staying with them in their small apartment. Barbara said that her “family, on the other hand, was very removed and distant. The delivery itself was a forceps birth but there was a lot of difficulty building up to that moment when I had my daughter.” Barbara had an argument with her husband and he left just as she commenced labour. She called her sister for help but she was not available. Barbara went to the hospital and later, her husband, Bartoli, came to visit but left her during the night to get some sleep. After a long night of back labour, Barbara agreed to an epidural and progressed to full dilation. Then, a doctor came into the room and said, “‘we have some medical doctors who would benefit from witnessing a birth.’ I felt very dependent and vulnerable and not in a place to say no.” Next, she recalls “looking up from my knees and seeing these white coats, a row of doctors, mostly men, looking at my crotch. It certainly didn’t help me relax and be open and create a sacred and beautiful, rich experience.” They used forceps to pull out the baby.  Barbara remembers:     72      My immediate response was ‘Bring her to me right NOW!’ But they took her and measured her and this wolf in me coming out, I said, ‘Bring her to me NOW!’ This instinct emerged and I surprised myself. So there she was beside me and all the effort for the beautiful magical experience and she latched on.  Barbara’s expectations were eroded not only by the nature of the delivery but also in terms of her personal relationships with her husband and family. While she adjusted to early motherhood, Barbara’s mother-in-law was anxious to help but “there was this territorial thing in me that didn’t want anybody getting involved with my baby’s wellbeing.” Bartoli and Barbara had another argument, hurtful things were said and Bartoli, his mother and brother packed their bags and left the apartment. Barbara didn’t expect her husband to leave as well but eventually, Bartoli returned although things were very strained. They moved to South America, “so there were more changes and more upheaval for the next six months. I was very much alone during this whole experience.” Their relationship ended and Barbara moved back to Canada alone with her child. She speaks about her sense of isolation;  What is wrong with our society? We don’t have a clue how to support each other. Not a clue. Do it yourself. You made that choice—you live with that. ‘Yes, but there is a baby here’ and I become a single mother in all of that too. Again our society says you do it yourself and you go to work or you go on welfare and those are the options. And there wasn’t anything in between.     73      Impact of a Difficult Birth on Mothering  Barbara’s difficult birth involved an acute “sense of abandonment, which has become a large part of my own healing journey.” She described how she was very conscious of her experience and worried how her birthing experience might be felt by her daughter following her birth. Barbara’s difficult birth affected her sense of mothering and the discord generated at that time resulted in her marital relationship ending in divorce and a crisis in her life.  I became a single parent. It totally impacted my mothering and how resourced I was and what I had to give. The stresses that were around me and the things I had to move through, it certainly made me a stronger person. It gave me a lot of purpose. It really brought to the surface what I value. In some ways it brought together my earlier experiences of abandonment to the surface for me to look at so it can be healed as well. Carol: Narrative of Difficult Birth In her late twenties, Carol married and moved to the southern United States to be with her new husband. In 1987 Carol became pregnant while she was working in a large hospital as a medical-surgical nurse. At a routine doctor’s appointment, they discovered she was in preterm labour. “I literally went into full blown labour every night and it was back labour.” Carol was seen by myriad of specialists trying to determine what was going on in order to stop the labour. She underwent ultrasounds, various tests, X-rays, dyes and medications. Carol said she was placed on tocolytics to stop the labour, analgesics for pain, antibiotics, as well as many other drugs. The goal was to keep the foetus in utero until its lungs were mature enough to survive outside the mother’s body. This was a lonely time for Carol as her husband worked away.      74      One doctor finally diagnosed a kink in the ureter that was causing nightly labour pains. They inserted a stent and the labour stopped. Carol was given a course of antibiotics and sent home but her membranes ruptured and she returned to hospital where she underwent a caesarean section. The baby was born preterm at 30 weeks’ gestation.  Following the birth, Carol suffered from intractable nausea for two weeks and remained hospitalized. A psychologist came in to see her, as well as a gastroenterologist, who asked “What do you think is making you so sick?” Carol said she felt it was all the drugs. So they discontinued all medications and she began to feel better. By the time she went home she weighed 97 pounds. “I think it was the iodine because I kept saying, ‘I can taste the iodine.’”  Carol managed to breastfeed her baby through this period with the support of her mother and father. She says her husband, was just too young or something. He didn’t get it. He couldn’t cope. Maybe he didn’t understand the seriousness of it or any concept of what it is to suffer. So there was ‘a disconnect’ for me with my relationship with my husband.  Impact of a Difficult Birth on Mothering  The difficult birth affected Carol’s mothering over time in that it reinforced the perception of herself as a good mother. She identifies herself as a source of strength and protection. She described having some hard years being a single working mother. She explained that the lesson she learned through the difficult birth experience was that “you must survive; you have to do whatever it takes to get that child into the world.” Carol recalls her birth, postpartum recovery and questioning of her ability to continue with her profession.      75      Honestly, after [the birth] I didn’t know if I could really be a nurse again. I thought this was a torture chamber. It was a torture chamber—and then there was [the baby] Carryn. Not being strong myself and then a C-section. I was lower than my pre-pregnant weight before I left the hospital. Even my legs had atrophied. There was nothing to me because I was throwing up.  Carol’s marriage ended, which she feels was related to her husband’s lack of empathy and understanding for their first child, who suffers from attention deficit disorder. She pondered the love she feels for her difficult birth child.  I guess I’m just more aware of the preciousness of life and how things can start out a certain way and then they can change unpredictably. Just honouring that and not to take things for granted.  Diana: Narrative of Difficult Birth Diana became pregnant after dating Dennis for several months. She was 19 years old and lived with her mother and sister during the pregnancy. At term, Diana was induced for her first and only child. Prostaglandin gel was inserted in the cervix and then she was sent home to await the commencement of regular contractions. Later that evening, Diana felt the first contractions. She returned to the hospital and “they decided to use” the drug oxytocin intravenously to enhance labour and Diana experienced a spontaneous, small rupture of her membranes. Diana told me her mother, who was maintained on methadone, had delivered her own infant, Diana’s brother, ten weeks earlier. Labour progressed and Diana began to vomit (a sign that labour is moving along). They gave her Demerol (pethidine), which allowed her to sleep between contractions but she awoke vomiting and contracting. Next they performed an artificial rupture     76      of membranes and there was meconium present. Then they gave her an epidural and she dilated to ten centimeters. She pushed for three hours and then her physician called in the obstetrician for assistance. Diana recalled “I was young, 19, and my first pregnancy. I also did not do prenatal classes. So they were concerned that things weren’t moving along because I didn’t know what I was doing.” Diana described the birth where forceps and “fundal pressure were used to pull her baby out. The umbilical cord was wrapped around the baby’s neck twice. Once the baby was born all Diana could think was “Oh, you’re there—neat!” Two hours later, “I’m on the gurney [going] into the operating room. I had passed out because I had lost two pints of blood in the delivery. I had a tear in my cervix and an episiotomy that also tore.” Diana recalled her first few months following birth: “I remember us going home, I remember Halloween and Christmas.”  Impact of a Difficult Birth on Mothering  Diana said this was an experience she would not want to do again. She recalled the baby’s head being pulled from her body. She stated that it was a disappointing time. Diana told me, “What made it the biggest challenge was the doctor not explaining things to me. Not really explaining necessarily what was going on.” Further she shared that the obstetrician didn’t “come to check on me, the three days I was in the hospital. To me, I thought, that’s funny. You’re the one that looked over the actual occurrence. You were the one in charge. That part was challenging to me because it was just such a cold bedside manner.”  She set the context of her birthing experience and spoke of her two most recent concerns: her son’s recent seizure and her husband’s serious illness. Speaking about her birthing Diana said it was a disappointing time but it was formative and increased her capacity to deal with family     77      crisis. She said she learned about elements of caretaking and being reflexive as preparing her for other challenging life circumstances. Diana explained how the difficult birth affected her mothering. “I definitely have learned to pick my battles.” Diana’s son, born with the use of forceps, was now 12 years old and recently had a grand mal seizure.  There are certain things that are worth fighting over and things that aren’t. Now with the seizure, I’m going ‘Okay. No, you still need to go to bed at a decent time. You get to stay up half an hour later on the weekends because you still need to recover.’  Diana spoke about a friend with twins, one of whom also had a grand mal seizure. She supported her friend emotionally and listened to her story of going to emergency and seeing the pediatrician. The friend, Diana related, “Knows how important it is to know; the more knowledge you have is power.” Diana spoke of a conversation with her husband about her friend’s child, during which “I felt my anxiety instantly almost go through the roof, to the point where I was literally shaking in my hands.” Worries of other women trigger Diana’s memories of fear for her own child and their outcomes today.  Eileen: Narrative of Difficult Birth Eileen, in her early thirties, was at full term. She broke out in hives, was swollen and felt awful. The following day her water broke and later that night she went to the hospital. Eileen was prescribed intravenous antibiotics because she’d had rheumatic fever as a child.  At 10 o’clock, they said, ‘You’ve really gone into the hard labour now. It shouldn’t be long.’ Thirty hours later, she was finally born. So it was a very long process. For me, a lot of it is blanked out. I just remember being     78      tired and throwing up a lot. When the third set of nurses came in, one of the nurses looked at my chart and said ‘Why hasn’t she had anything to drink?’ ‘Well she throws it up.’ ‘Well why doesn’t she have ice?’ ‘She throws it up.’ I couldn’t even have the ice chips. And she said, ‘Well she’s really dehydrated put more liquids into the IV.’   Maternal dehydration causes ketosis and is toxic to the foetus. Eileen trusted her body to do the work of giving birth. She recalled,  The doctor was yelling at me because she wanted to do a C-section and we said ‘Give us a little more time to just see if it happens.’ She was angry with me for going through with the vaginal birth [and we said to the doctor] ‘It hasn’t been that long and you’re not seeing any distress from the baby.’  She did deliver her infant vaginally. Eileen was hospitalized for a week afterwards and was refused discharge due to the infant’s weight loss. The baby lost a pound following birth, although she “had been breastfeeding well.” Both suffered from thrush due to the antibiotics, which took months to clear up. Eileen eventually signed herself out against medical advice. It took Eileen “a couple of months before [the stitches] healed.”  Impact of a Difficult Birth on Mothering  Eileen recalled the difficult birth heralded a starting point of great significance for her and her family. When asked what made the labour difficult she replied, “The fact that I couldn’t move around very freely because of the IV. I just remember throwing up a lot. Nobody ever warned me that I’d throw up.” She told me what made the birth difficult was     79      the length, the exhaustion and then at the very end … the ripping. I can’t remember how many stitches it was but I’ve still got the scar from it. Then the recovery; how long it took and how exhausting it was.  Immediately following the birth, Eileen stated she breastfed her infant. Her husband, Evan, left work to care for her and the baby and did all of the household tasks until she recovered. I didn’t do very much mothering. Evan did all the mothering from the time we got home. I fed her and that was my job [laughing]. She was still feeding at night when she was two. I think that part of the difficult birth … was very traumatic for her for it to take so long to be born.  Eileen ruminated about the connection with her child that stemmed from the vulnerability at birth.  Having the difficult experience makes you feel your child’s more precious. It really gives you that feeling when something’s a little more difficult to obtain, it becomes more important. It was a lot of work and it makes you realize how precious this person is and you take more caution or better care.  The difficult birth affected the bond between Eileen and her child.  Because it was difficult it increased the intensity of care; that desire to do things to the best of your ability to really be that effective caregiver. I think if it had been easy, I wouldn’t have that same awareness. Francis: Narrative of Difficult Birth Francis says she chose a midwife for her pregnancy. She confided, “I was doing this later in life, so I waited a very long time” to have a baby. There was some confusion about her due     80      date and it was estimated that she was one week further along than she believed. At 42 weeks gestation, or 41 weeks by Francis’ calculations, her midwife explained the potential of death for post-date infants. Francis said “All I heard was dead baby” and agreed to an induction. On Monday, after the non-stress test, an obstetrician inserted prostaglandin to induce labour and she was discharged to come back to hospital when labour was established. Returning later in the day, she recalled being admitted to a small windowless room. Francis said “I felt like I was stuck in a closet and that is not a great way to feel when you’re having a baby.” From the moment labour started Francis said it was relentless. Her midwife was busy with another delivery and she felt alone. Francis recalled, “I remember my left hip being out of joint. Later we realized that’s where his head was. It was pushing sideways it wasn’t pushing forward.”  When she was fully dilated, Francis pushed for four and one-half hours. “He was ready to come out but he couldn’t.” At this point “I started asking for help.” Although the nurse attending Francis was told to go on a break, she “wouldn’t leave me. I asked for help and she went to get the obstetrician and he came a few minutes later.” Francis described “how time becomes irrelevant in these situations. You are just dealing with the moment and what’s happening. You leave your body most of the time at this point.” The obstetrician wanted to assess her pushing to ensure she was doing it right. Francis stated emphatically,  I went to acting school for crying out loud. I learned how to breathe down there. I’m breathing, I’m pushing, I’m doing all of this body work. Thinking, thank God I went to acting school so I could birth this kid. But he’s not coming out. So I’m in trouble.  Despite a trial of forceps under epidural anesthesia, the baby could not be delivered. Then Francis recalled “being wheeled into the OR not long after that.” All of her plans and hopes for a     81      nonmedicated birth were dashed. The baby had passed meconium and the pediatrician was there for his care. Frank, Francis’s husband, told her they had a boy; she was elated. But “I felt cheated, I felt like it had gotten away from me. I felt shame right away. You go back and you think, ‘Where could I have done this differently?’” Francis recalled crying in the midwives’ offices for six weeks. Her incision was infected and it would be a year before the wound stopped weeping pus.  Impact of a Difficult Birth on Mothering  When I asked about her birth experience and how it affected her mothering, Francis replied thoughtfully, “After you have a disappointing traumatic experience when you birth, the things that happened afterwards are so important because you can empower yourself later. That’s all you can do.” She told me that the difficult birth set in motion a type of “pushing and pulling” in the relationship between her and her child. She looked back and reflected on her experience that resulted in living and working through feelings of grief and shame with the loss of her ideal birth. She told me these feelings were less now, since his birth seven years ago.   Gillian: Narrative of Difficult Birth In 1979, when she was 19 years old, Gillian married Gary and was soon pregnant with their first child. She had a very healthy pregnancy and, like Diana, did not attend prenatal classes. Gillian described herself as being “very naïve and in denial, perhaps.” On Thanksgiving weekend she had worked through Saturday and on Sunday she cooked dinner and went bowling. On Monday Gillian was having contractions, although she thought she had eaten too much or perhaps needed to go to the bathroom; however, she was having contractions. She called a friend and then the hospital and was told to come in as her contractions were so close together. Getting to the hospital at 9 p.m. Gillian was fully dilated and ready to give birth. The doctor was called in     82      and they discovered the baby was in distress with a prolapsed cord. “Instantly,” Gillian said, “I’m having a C-section and the doctor shows up and it’s a big whirlwind. I’m in extreme labour now. I’m mad because I am having a C-section and they are all talking around me.” They rolled her onto her back from side-lying and she recalled, “My back was breaking in half from the excruciating pain.” Gillian was given a general anesthetic and when she woke she remarked, “I have a son.”  Gillian had little experience with babies and laughed saying, “I didn’t even know I had to burp a baby. He really never woke up except to feed and I don’t know if that was a result of the C-section or the birth?” Within a day or two, while still in hospital, Gillian became sick and so weak she couldn’t hold the baby, and a nurse accused her of rejecting the baby. Gillian replied, “‘I’m not rejecting it, I just can’t hold it.’ I was in so much pain. I ended up having a pelvic infection that went undiagnosed for a whole week.” She reiterates how the nurses were horrible to her, insisting that she get up and walk to the end of the hall and to the shower. “I had a fever, I had incredible pain and I didn’t know what was happening. Nobody was listening to me. I felt terrified.” She asked her husband to call her mother but he insisted that he didn’t need to phone her yet. The following Sunday night,  I remember a nurse sitting with me. It was dark and she sat in the corner. It was like she was an angel to me. I remember this soft light around her and she said, ‘I’m not supposed to tell you this dear, but you are very ill. You need to get another doctor. You are very sick. I can lose my job for saying this.’   The next morning, Gillian told her husband to get another doctor. The angel nurse had told her to call a specific obstetrician from a nearby town.      83      So he came in that morning; looked at me and the chart. He touched me and I just about hit the ceiling [with pain] and he made things happen ‘STAT.’ There was a flurry of nurses moving me to isolation, IV antibiotics; I had to be given blood. I was so grateful.  Gillian was in hospital for another week recovering from the pelvic infection. “All of a sudden I start to feel better when they [gave] me the blood. Wow, I feel human again.” Her mother came to stay for a one month stay while Gillian recovered.   Impact of a Difficult Birth on Mothering  Gillian spoke of the impact that the difficult birth had on her mothering over time, she said,  Right off the bat having a C-section made it difficult. Probably my ignorance made it difficult. If I really had wisdom, knowledge and an awareness and ownership of my body and was really actively participating in my pregnancy and owning the birth process … but I just so wasn’t there. I didn’t have anyone encouraging me to do that. I didn’t have a natural inclination to do it, which was interesting. I don’t know why. Because you’d think as women … doesn’t that just happen to us magically?  She went to describe how overwhelmed she was at that time. “I was just at the mercy of everything happening to me. And not having a husband who was really into it and on board either. Then all the other complications made it very difficult too.”  Within several years, Gillian goes onto have two other children, a boy and a girl; both these children have a rare form of microcephaly and require intensive daily care. She cares for     84      them herself with little support. “We had our own business, a bakery. I worked. I’d get them up in the night and take them into the bakery, put them back to sleep. Then they’d all wake up and I’d feed them. I was just stupid. I don’t know how I did it.” After several years she had a “nervous breakdown” and eventually both children were placed in care.  I carried a lot of guilt for years about my children. I struggled; especially when I let them go into care. It was brutal because I kept thinking I should have them. The Ministry [of Children and Family Development] should support me so that I could stay home and be with my children. I fought against that for years. I went through depressions and it was hard. Truly only in the last four years, I’ve kind of forgiven the Ministry. I’ve forgiven myself. I’ve just accepted that this is the way it is.  Hillary: Narrative of Difficult Birth Hillary became pregnant in her early thirties and gave birth to her first child, a daughter, ten weeks prematurely. The delivery was spontaneous and happened within a two-hour period. In the middle of the night, Hillary had gone to the hospital thinking “something was wrong; that intuition, something is not right. I was told, ‘No, no, you’re imaging it. You’re being paranoid. Just go home.’” She was told that it might be indigestion. Hillary refused to leave the hospital until she saw her obstetrician at 6 a.m.  She described a need to bear down and recalled “I actually felt her head. My husband ran out in the hallway and started screaming. A nurse came running in and she believed me, she’s the one who delivered her. She was an amazing, amazing nurse.” Many preterm infants are not ready to breathe when born so early and Hillary felt lucky that morning as the head of the respiratory therapists for the province was in the hospital to give a talk and he was able to intubate the infant     85      (place a tube in her airway). “I was so lucky, it’s incredible really that those events came together but it was definitely shocking and very traumatic.” For several days nobody knew if the baby was going to make it. “The baby was without oxygen for some period of time, who knows how long. He intubated her quickly, within ten minutes, but the whole birthing process was probably going on for at least an hour, probably two, before that.” Hillary was fearful, and was not able to hold her daughter or feed her because of the all tubes the baby required to breathe, plus a nasogastric tube for feeding. “She was taken off the full machine that made her lungs pump, so after day five we could pick her up and hold her.” Hillary’s baby remained in hospital for five weeks. Of her birthing experience Hillary said, “There was nothing positive about it. It was terrifying and scary. It was really beyond words. You don’t know if your child is brain damaged, whether she’s going to have lasting effects, whether she’s going to live.”  Impact of a Difficult Birth on Mothering  Hillary’s difficult birth affected her mothering due to the circumstances of prematurity and not being believed when in labour.  I was terrified because it was my first child. My mother passed away when I was five, so I had no one with me other than my husband, who was great, but he was hysterical too. I was just unsure about what was happening. I really felt that no one was listening to me. So that was the hardest part of that moment.  She described her feelings of utter fear for her child, feelings that instigated her need to advocate for her children and family members in a different, more intensive way. Her difficult birth “made me a different parent than I would have been, if she had been born full term or if she     86      had been born in a more thoughtful way.” Because of the drastic nature of the birthing experience, Hillary didn’t want her daughter to feel her fear and terror from the birth. For Hillary it was a dreadful time of worry. She recalled filling out the baby book about one year following the birth and pondering what she should write. Hillary said she decided that she couldn’t pretend her daughter wasn’t born prematurely. So, she wrote that her daughter decided to come into the world early and fought right through it all. Hillary was resolute to make the birth story about her daughter’s strength instead of “how horrible it was for us at that time.”  She recalled wanting another child and trying to find answers to why this had happened to her.  I actually did go through some therapy before I had my son. Because I thought I can never have another child, never; even though I wanted another child. Nobody could tell me why it happened. I felt very much like I was ignored in the moment and I thought I can’t do that again.  Isabelle: Narrative of Difficult Birth  Isabelle had two children prior to her difficult pregnancy and birth, one son with a disability aged two and another son aged five. She recalled that she was 31 weeks pregnant and noted this “last [birth] was the worst.” She developed terrible abdominal pain, which turned out to be a ruptured appendix necessitating emergency surgery and twelve hours post-operatively, she went into spontaneous labour. Isabelle reported her husband was with her and she was “so doped up with analgesics that I was a little bit out of it.” The baby was high in her uterus, so it took a long time to push him out. Then the cord was around his neck and he was in distress. Isabelle told me “the nurse turned off the [fetal monitor] audio because it was too stressful when the heart rate would go down, down, down.” When the baby was born he was “really blue … and     87      then they took him away to the ICU (Intensive Care Unit).” Isabelle described the experience as being  surreal. I don’t even really remember the whole first year of the baby’s life because I was so exhausted from the birth and being sick. I also suffered from terrible postpartum depression as well. So, it was a pretty stressful time. You don’t realize how serious it is until the doctor says, ‘We’ll worry about you and then we’ll worry about the baby.’  Impact of a Difficult Birth on Mothering  Isabelle stated the difficult birth had affected her over time and that it was part of the legacy of the protectiveness she felt for her tiny child. She said she had always been protective, an advocate, fighting for her children’s rights, particularly for her child with a disability and for what disabled children need.  It made me overprotective at times and I’ve had to learn to let go of things. I still have a tendency to rescue [laughing]. When they were young, it was more emotional rescuing and trying to pull them back in and make sure they’re safe and happy; always providing and making sure they weren’t hurt.  Isabelle questions herself and tries to make up for the preterm birth by being a more ideal and perfect mother.  It also created high expectations of how to mother for me. I had to be a really super mum to make up for this traumatic birth and prematurity and [in addition to her] special needs, brain injured child. I had to be a super     88      mum to compensate for that sort of failure. You did feel like it was a failure. You’d failed them somehow.  Jennifer: Narrative of Difficult Birth Jennifer was pregnant at 30 years old with her first child. When she got pregnant, she was working in silvaculture, which involved spraying pesticides. She remembered “moments of being stuck in the bush and just really taking huge whiffs [of pesticides] and thinking to myself ‘This isn’t good.’” The material safety data sheet (MSDS) on the specific pesticides she was spraying showed no teratogenic effects on an embryo/foetus. By the time she was at ten weeks gestation, she switched to office work for health concerns. Jennifer’s pregnancy was uneventful, but looking back now she says, “I see red flags.”  Jennifer’s membranes ruptured two days after her due date and labour commenced. She went to the hospital and was contracting every three minutes. After 12 hours a nurse noted something wasn’t right and with closer examination noticed the baby was in breech position and Jennifer underwent an emergency caesarean birth. Prior to discharge Jennifer was not given information on pain control. Being an independent person she asked for little help. Six weeks following the birth Jennifer experienced postpartum depression. She recalled that she had hematomas all along her incision line, which her doctor said was normal. However, her mother, who was a nurse, said there was something wrong with the incision.  Her energy depleted, all Jennifer could do was breastfeed the baby, then hand the baby off to her partner Jeffrey or her mother. For the first six weeks, baby Jade “didn’t really show too many signs of anything.” She was gaining weight but she was tiny. By eight weeks she started to develop nystagmus “then it got, obviously, worse.” Jennifer called the nurses’ hotline and they recommended she see a physician, who referred her to an ophthalmologist, then to a pediatric     89      ophthalmologist, who diagnosed congenital nystagmus. The pediatric ophthalmologist reassured Jennifer that surgery should fix the problem. However, in the “worst case scenario,” Jade could be legally blind. Jennifer was scheduled to fly to see her mother in eastern Canada. Jade had not gained weight in a month and Jennifer’s doctor admitted the baby to hospital for failure to thrive. The doctor told Jennifer if she wanted to fly, she could always go into the hospital there. Jennifer called her aunt, who was also a nurse, who advised her “No, you don’t get on the plane, you stay in the hospital.” So Jade was admitted to hospital and the nurses assessed Jennifer’s breastfeeding although Jennifer stated breastfeeding “was never an issue for us.” The pediatrician wanted to do an ultrasound of Jade’s brain before discharge. As Jennifer was packing to leave, the nurse asked them to stay as the doctor wanted to speak with them. After three hours, Jennifer and Jeffrey knew something was awry. The pediatrician announced “There’s a brain tumor,” referred Jade to a children’s hospital and Jennifer was discharged home with her baby. The next day Jade would not breastfeed so they returned to the hospital and were transferred to a large children’s hospital. Jennifer was allowed to travel with the baby when she was airlifted but Jeffrey had to drive. Once there, Jade was sedated and had an MRI and “that was the last time she was ever really awake.” Jennifer signed consent for a shunt to release the pressure on Jade’s brain. “The second they released the pressure she was in excruciating pain for 48 hours” before they could get the pain under control. “She screamed the entire time, then she started to seize constantly.” Jade was moved from the ICU to the neurology ward, and then, “because it was cancer,” to the pediatric oncology ward. Jennifer’s parents flew in to be with the family. Jennifer recalled the conversation with the physicians and palliative workers: “They started off with blah, blah, blah an anaplastic astrocytoma is this … I just completely interrupted     90      them and said ‘How long do we have?’ And he said ‘At best three weeks.’” Fourteen days later Jade stopped breathing.  Impact of a Difficult Birth on Mothering  Jennifer spoke about her caesarean birth experience, how it affected her and the additional complication of postpartum depression.  Initially the birth experience with Jade, obviously, made it difficult to mother because of having a C-section, having a major surgery, being in pain. It made it difficult to complete all those tasks, all those everyday things. Yes, it did, definitely, one hundred per cent.  In addition, the loss of their child was devastating and life changing. Jennifer said that after a great deal of soul-searching she and her husband, Jeffery decided to have another child. She spoke about her birthing experience with this child.  Now, the second time, again difficult to complete those tasks, everything, but not having the PPD involved, definitely easier. Jennifer said she would be interested to hear what other women say about their births.  To talk to somebody who had a ‘normal’ typical experience where it progressed and everybody was healthy and they went home after 48 hours. I wonder what difficulties they had. They must have difficulties? It’s not like birthing a child is easy. It affects you physically. Everybody, right after birth, has hormones going on, that’s difficult to balance. Jennifer reflected about the life transition for women and noted that all births have a deep impact on the mother for many reasons.      91      I think mothering is such a huge responsibility. As much as we take it on, we want it and we love it, when you have it, how could it not affect your mothering? Whether you have a good birth or a bad one, either way you have trauma to your body. You have a new one [baby] that’s very unpredictable, unstable initially. You’re balancing a lot.  Karen: Narrative of Difficult Birth  Karen recalled her first child was born by a caesarean section due to a prolapsed cord. She described it as “an intense but quick experience.” With her second pregnancy, Karen suffered kidney stones and required stents to be put in her ureters during pregnancy. “I was very uncomfortable and painful and sick during the pregnancy. So my doctor decided to induce me at 38 weeks. They were doing a study at the hospital and I was a study participant.” She stated, “no, I don’t remember signing anything” about consent to be enrolled in the study. “They were doing a study on the placebo effect of prostaglandin. So they gave me some prostaglandin or not prostaglandin and sent me home.” For three days Karen went back and forth to the hospital until she was in active labour. “I felt absolutely horrible and exhausted. I hadn’t been sleeping. All I can really remember in the labour room is people telling me that I needed to push.” Karen’s mother and father were also present at the birth and Karen told me it was the only birth they had ever seen. “My doctor yelled at [my father] to open the door and yell SCN (Special Care Nursery). So he opened the door and said ‘SCN, whatever that means’” and the special care nurses came in.   Karen was in “massive pain from the kidney stones” and baby Kalen was “born flat, not breathing and not doing well.” They whisked him away and neither Karen nor her family was given any information. When Karen finally saw him,     92      His head was shaved and he had an IV in his hand, a lot of bruising on his head and I was crying. I never really knew what happened. What makes this whole experience so traumatic for me is that I didn’t even realize how little I knew about my own birth experience until I was educated [as a RN] and until I did my NRP (Neonatal Resuscitation Program). I have since called them [the hospital] and asked if I could get my records from that birth. [They asked Karen] ‘What particular part of that do you want?’ ‘I want it all!’ [Karen replied] Again, the response was, ‘Well, no, what part do you want?’ Karen said, 17 years later “I don’t even know what his Apgars were.”  Impact of a Difficult Birth on Mothering  Recalling the birth of her son Kalen, Karen said, “He’s the fragile one to me [laughing].  So, I’ve taken that with us.” As a nurse she works with birthing women and talking about birth is part of her everyday experience. However, Karen said that she doesn’t discuss her deliveries. She only says, “I had a C-section, a back labour and delivery and a vaginal birth.” Karen stated she doesn’t go back to that time and she doesn’t bring up Kalen’s birth experience. Further, she has not told her son about his birth. She wonders what she would say. “‘When you were born, wow, what a gong show that was.’ He probably doesn’t even have any idea” [laughing].    Describing the effects of the difficult birth on her mothering and on her thoughts about her son, Karen said,  He is different. They’re all three different but he’s definitely. He’s like the thinker. He doesn’t just blurt out stuff. I don’t know, I expect greatness from him, which is interesting, because I think it’s why I get so     93      disappointed when he plays video games all the time. ‘Don’t you want to do more with your brain?  I know you do. Come on’ [laughing]. He goes to the alternate school because [regular school] is not a good fit for him.  Karen still carries anger around about her son’s birth. She described her experience of being bullied and enrolled in a study on prostaglandin, which she sees as abusive. She feels her rights were ignored and the nature of the induced labour put her child at greater risk with no explanation for his suffering. Lyanne: Narrative of Difficult Birth  Pregnant with her first and only child, Lyanne was in a relationship with her long-term partner Linda. Prior to the birth, Lyanne was hospitalized for several weeks for intrauterine growth restriction and she delivered her daughter ten weeks early. “She was just two pounds at birth and the first 72 hours, they told us it was touch and go.”  Lyanne experienced some “very unusual pains and went to emergency for an ultrasound. [They] discovered that [I] didn’t have any amniotic fluid, the placenta was not great and the baby was underweight.” Lyanne had placenta previa, which was not disclosed to her by her physician, and she was transferred to a larger hospital. The obstetrician decided that she didn’t need to be delivered that first night but after two weeks the fetal heart rate began to “dip quite a bit.” Dropping foetal heart rates without labour indicates that the child is in danger particularly with oligohydramnios or low amniotic fluid volume. The obstetrician was concerned, “he said, ‘What do you think we should do?’ I said, ‘I think she needs to be delivered.’ So they took me later that night.”   The caesarean section, Lyanne described, “was quite traumatic because they wouldn’t let Linda in until they had prepped me, I was already really scared. I couldn’t understand why they     94      couldn’t let her in for the epidural and the prep.” Even if I’d had a normal birthing experience it would have been difficult for me because of my sexual abuse history. I know that it made the whole C-section more difficult too, because of having my arms strapped down.”  When Lara was born, “she was blue. They worked on her [because] she wasn’t breathing. So, they got her breathing and they showed her to us and ran down the hall to the NICU (Neonatal Intensive Care Unit).” Lyanne’s birthing experience was further complicated by the baby’s inability to breastfeed. However, Lyanne pumped her breasts and gave Lara the expressed breast milk. Lyanne was hospitalized later for postpartum depression and hypothyroidism and eventually gave up pumping her breasts. Impact of a Difficult Birth on Mothering  Speaking of how the difficult birth affected her mothering Lyanne describes her hospitalization whilst pregnant.   Well, number one was the emergency of it. That this has to happen and ‘Oh my God, it’s not time.’ And ‘what do you mean I have no amniotic fluid?’ What did I do wrong? I started to blame myself. Waiting in the hospital for two weeks and not knowing what the heck was going to happen.  Her difficult birth affected her mothering, in that,  It’s made me more hyper-vigilant around her. That’s something I have to work on daily. The first several years I was always worried, especially the first year. I think it just sort of triggered me; my nervous system was always on the edge of when an emergency was going to happen for her.   Caring for a preterm infant requires unending vigilance for the parents.      95      In the beginning when she was a baby, there was worry, more worry about things. Like she had some problems with her legs and on her first birthday she couldn’t even sit up by herself. So everything was quite delayed; there was concern if she would walk. There was physiotherapy and I was always trying to make sure we were doing the right thing to enhance her development.  She speaks of her daughter’s health today, I feel that it was such a gift that she’s healthy; it could have been very different. So, I just treasure her even more because of that. I can’t imagine – not that I love my daughter more than any other mother loves their child, but there’s just something … like, we made it!   Lyanne reflected on how much she does for her daughter today and the pattern that was created.  I think sometimes I do too much for her that she could do herself. I think that’s complicated because I see that as my job. I have to let go and let her be more independent. She can cook and make her own food but I like to make it for her. Linda’s always at me about that; ‘She can do it herself.’ ‘Yes, she can; but, I want to’ [laughing]. It has all been difficult for Lyanne to work through; each of her daughter’s birthdays was an anniversary of a trauma and that it wasn’t a joyous event. As Lara has grown and matured, however, Lyanne continues to process her own trauma.   This chapter has introduced each of the women in this study and they have shared some thoughts on their difficult birth and the impact it had on their mothering. Their thoughts and further details of their birth will be shared throughout the remainder of this document. In the     96      following chapters I discuss prenatal surveillance and preterm birth (chapter four), birthing women’s struggles and medicalized births (chapter five), unethical treatment (chapter six), being left alone (chapter seven), and vulnerability and mothering (chapter eight).      97      Chapter 5 Embodied Pregnancy and Preterm Births Women experience pregnancy through many conscious and unconscious layers of awareness. Pregnancy is a physical and a psychic (read soul) experience that is embodied but is also experienced as a public display of bodily change. Mental changes and adjustments are necessary as the pregnancy progresses, requiring on-going negotiation and accommodation of self and with others. Embodiment of pregnancy is the woman’s intimate lived interpretation of the experience. Merleau-Ponty (1999) emphasizes it is through lived experience that one perceives their world. Grosz (1994) argues that Merleau-Ponty’s sense of the body as interpreting one’s world of experience aligns with the body–subject that supports feminist thinking. Merleau-Ponty’s understanding of lived experience has three crucial insights. First, he feels that embedded in experience are social, political, historical and cultural forces which cannot provide an outside vantage point for judging individuals. The construction of experience is, at the same time, active and passive functioning; its role is both inscription and rebellion of sociopolitical values and speaks to the unspoken assumptions of women’s experiences worthy of exploration (Merleau-Ponty 1999). Arguing that understanding experience is part of the production of knowledge, and thus legitimate, Merleau-Ponty argues the starting point of exploration of women’s experience is through understanding a woman’s lived reality.  Merleau-Ponty (1999) connects experience to consciousness, he also regards experience as always embodied, corporeally constituted, located in and as the subjects’ manifestation. Thus, experience can only be understood between the mind and the body—or through them—in their lived conjunction. The pregnant woman, who knows herself through her highly attuned body, notices and interprets every nuance and change. A woman also knows her foetus and, with that     98      knowledge, the birth of her child brings about great changes to her understandings, known through her body. As pregnant women live and experience their world through their bodies, their pregnancy and childbirth are constituted through their embodiment. For a woman there is no other time in her life when she is more aware of her own embodiment than when she is pregnant (Bondas and Ericksson 2001).  Merleau-Ponty’s (1999) insights of interpreting one’s own world as legitimate provide validity to women’s corporeal experiences by taking her embodiment seriously. The authority that a woman possesses of her own embodiment is often denied or rejected on admission to hospital. Honouring women’s subjectivity recognizes the mind and body as valid; however, HCPs scrutinize every aspect of pregnancy and the pregnant body, thus appear to control and keep women as objects. Technological approaches override a woman’s sense of self. When women follow medically regimented recommendations they are viewed as compliant but when they question procedures, women are seen as renegade and encounter repercussions.  This chapter examines the notion of embodied pregnancy and corporeality up to, during and following delivery, particularly as those women who experienced preterm birth share their stories and struggles. Also within the chapter, I expand on the concept of surveillance and themes of participants’ experiences are extrapolated for further insight to their intimate, lived interpretations of the difficult birth experience.  Structured Surveillance  Surveillance is about assessing a woman’s state of health in pregnancy and comparing her status to discourses of normalization information to define if she is “at risk” (Lupton 1999).  All throughout pregnancy women are under a structured routine of surveillance from care providers who monitor all aspects of their health to ensure a healthy mother and foetus. Each     99      month, medical surveillance of the pregnancy is structured with routine tests, blood work, vital signs, urinary analysis and monitoring to ensure all is progressing within normal limits. Not only are physicians, midwives and health professionals capable of assessing a woman’s health condition, but so too are family members, friends and even strangers who share pregnancy and health advice, often times unsolicited, for women to take up and comply.  The pregnant woman is no longer permitted to drink alcohol, restrictions that are normalized within North American culture. It is now common to see notices in restaurant washrooms and liquor stores warning of the dangers of alcohol consumption when pregnant (Bordo 2003). If a woman smokes cigarettes (Powers et al. 2013) or marijuana, uses traditional medicines or other non-traditional health care practices, the woman may be seen as uncaring, selfish and the public feel justified in their righteous expressions of her unfitness as a prospective mother. Pejorative opinions are not uncommon, potentially leading to disparities in care (Kerker et al. 2004). The adjustments women make during pregnancy affect relationships, work and family. Pregnant women confront many emotions such as thoughts of giving birth, choices of care provider, dealing with fears and other concerns (Bondas and Eriksson 2001; Howarth 2010). Initially, many women face the prospect of medicalized care depending upon their health during pregnancy (Davis-Floyd 2001). Women and often their partners attend antenatal or prenatal classes in the final trimester to understand the bodily processes she is experiencing, to learn about hospital routines, fetal and infant development, labour, birth and breastfeeding (Morton 2009; Nichols 1995; Schott 2003).  Close monitoring is not uncommon, particularly when the woman’s health is doubtful, where conditions involving the infant may place the mother or foetus at risk or, where pre-    100      existing conditions may require careful monitoring of the woman’s diet, activities and environment (Cahill 2001; Chalmers et al. 2012; Cindoglu and Sayan-Cengiz 2010; Goodwin-Smith 2012).  Surveillance objectifies the woman by increasing the observation and control of women to ensure the health of the foetus (Duden 1993). Many of the women in this study complied with directives or recommendations issued by HCPs. As part of structured surveillance they kept appointments, attended clinics for check-ups, screening or education (Wetterberg 2004). Structured Surveillance Through Antenatal Education Women’s prenatal education is typically focused on labour and birthing practices developed by HCPs and offered in the final weeks of pregnancy (Svensson et al. 2008). Over time, care prior to birth has moved from care facilitated by lay women and midwives to a more technological and scientific process controlled through physician or midwife visits (Mitchinson 2002; Wertz and Wertz 1989).   Today women look to television, computer sites (Stoopnikoff  2011) and print material to gain information about pregnancy, birth and childrearing (Morris and McInerney 2010; Morton and Hsu 2007). Pregnant women have their own cultural expectations of anticipated food cravings, morning sickness, enlarged breasts and other changes to their body (Davidson et al. 2012). In a study of women’s thoughts about pregnancy, researchers found that all the participating women “consciously and some almost constantly thought about how their health habits would affect the baby’s health” (Bondas and Eriksson 2001:828). Many women felt they should exercise but were uncertain about what they could do because they were afraid of harming the child (Bondas and Eriksson 2001).     101      Prenatal care, a form of surveillance, also involves the selection and development of a support team of family and health care providers (Province of British Columbia 2013) to “ensure” a healthy pregnancy. Surveillance is potentiated through much of the information health provider collect from pregnant women for health maintenance (Perinatal Services BC 2013). The ongoing scrutiny of structured surveillance treats all women as “patients” with illness expectations, turning every pregnancy into a potentially dangerous time (Goodwin-Smith 2012). Pregnancy is defined as pathological and life threatening, aligned with sickness, with physicians looking for symptoms and diagnosis (Davidson et al. 2012) and comparing a woman’s pregnant state with her normal non-pregnant state (Mitchinson 2002). Biomedicine is organized to determine statistically acceptable variation among pregnant women.  Prenatal classes are designed to prepare the woman, that is, to make her compliant with the hospital processes of labouring and birthing. Women are inculcated into the practices they may be offered, which are “normal” for the HCPs but are invasive and risky for the woman and her foetus (Lothian 2006a; Stoopnikoff  2011). Women are taught exercises to learn how to breathe (Dick-Read 2004), as if they did not know how to d