Autonomy, clinical freedom and responsibility : the paradoxes of providing intrapartum midwifery care in a small maternity unit as compared with a large obstetric hospital : a thesis presented in partial fulfilment of the requirements for the degree of Master of Arts in Midwifery at Massey University

Small maternity units are an important historical feature within New Zealand. Over time many of these facilities have been closed and birth has increasingly occurred in large obstetric hospitals with the availability of technology and on-site specialists. A qualitative study using Van Manen's (1990) method of hermeneutic thematic analysis has been designed to answer the question: How is the provision of intrapartum care by independent midwives different in a small maternity unit, as compared with a large obstetric hospital? Ten independent midwives were interviewed, and data were analysed to uncover the meaning of the differences when providing intrapartum care in both small and large maternity settings. There are two data chapters that contain substantial extracts from the midwives' transcripts in order to illustrate the themes identified from the analysis of their narratives. 'Real midwifery' shows that independent midwives feel more autonomous and are able to let the labour 'be' when practising in the small maternity units. The midwives use their embodied knowledge and skills to support women to labour and birth without technological interference. In contrast, the midwives feel that employing technology such as fetal monitoring and epidurals at the large hospital, places the focus on the machines and the midwife does not use all of her skills. The second data chapter, called 'carrying the can', illustrates the additional responsibility that can at times be a worrying responsibility in the small maternity unit. When practising in the large obstetric hospital, specialist assistance is nearly always at hand and the midwives are considered to be practising in the safest place according to the dominant medical model. The paradox for midwives practising in small maternity units is that while these are a setting for natural birth, the midwives need foresight and confidence to avert or manage any problems that might arise. When midwives practise in the setting of small maternity units, they are more autonomous and have the clinical freedom to practise unshackled by technology. The art of midwifery might be lost if midwives continue to practise midwifery only in medicalised environments