"The best birth is one I'm not involved in": how do obstetricians construct a positive birth?

Portfolio Abstract Introduction The psychological experience of giving birth has been found to have a long-lasting impact upon the wellbeing of the woman and the mother-infant interaction (Ayers, Eagle, & Waring, 2006). Research has been carried out to investigate what influences the psychological experience of giving birth and contributes to these longlasting consequences. The interaction between the woman and the health professional has been shown to influence the psychological experience of birth (Ford & Ayers, 2011; Söderquist, Wijma, & Wijma, 2006). Despite these findings, obstetricians are a relatively neglected health profession within the birth research literature. Furthermore, obstetricians’ involvement or ability to contribute towards positive birth experiences has not been fully researched. Women have either emphasised the importance of the support they received from obstetricians or criticised the lack of support they received (Howarth, Swain, & Treharne, 2012; Simkin, 1991; Simkin, 1992; Waldenström, Hildingsson, Rubertsson, & Rådestad, 2004). The role of any caregiver during labour and birth is suggested to be important for influencing the psychological experience of birth (Anderson, Melvaer, Videbech, Lamont, & Joerhensen, 2012). However, obstetricians attend medically complex births where there may be mother of baby medical complications. Such births have attracted debate in the research literature. Complex medical births are argued to constitute a risk factor for negatively influencing the psychological birth experience and impacting upon the long-term wellbeing of the mother and infant-mother interaction (Anderson et al., 2012). However, other research has suggested that complex births are not always a risk factor for experiencing birth negatively and that the psychological (Nilsson, Thorsell, Hertfelt-Wahn & Ekström, 2013; Simkin, 1991, Simkin, 1992). Objectives The objective of this research project was to investigate the way obstetricians talk about giving birth, or ‘obstetric discourse’ and how obstetricians ‘constructed’ a positive birth experience. This research project aims to initiate the thorough investigation of spoken obstetric discourse, so that future research may build upon these findings. Previous literature has investigated the discourse about birth via interviews without obstetricians being the primary sample (Douché & Carryer, 2011) and has considered the discourse produced by obstetricians more broadly from published documents (Kitzinger, 2007; Licqurish & Evans, 2015) . However, there has been a lack of investigation about the spoken discourse of obstetricians. By adding focus to spoken obstetric discourse this study may potentially add variance to the data. Discourse is argued to be influenced by the context in which it takes place. Therefore research moving forward in this area may benefit from including varied contexts. Discourse analysis strives to highlight variance rather than a similarity (Potter & Wetherell, 1987). Striving to highlight similarities is argued to be invalid and accused of omitting potentially useful data from the research literature (Potter & Wetherell, 1987). Methodology The underlying theory and the accompanying methodology of discourse analysis was used to meet the objectives of this research project. A social constructionist epistemological stance was taken towards the gathering of knowledge in this research project. A social constructionist epistemology is compatible with discourse analysis due to the shared assumptions about language constructing experiences. From this theoretical framework, language is an important target for analysis because it is argued to shape human experience in terms of constricting or enabling what may be said, done or felt (Willig, 2013). More specifically, language is argued to create reality rather than accurately describe it. This study used a hybrid model of discursive psychology and Foucauldian discourse analysis. This involves analysing local discursive techniques such as disclaimers, contrasting and inferences about internal states, while also analysing wider social influences and the discourses available to the participants. For example, the discourse of medicine may be argued to be an available discourse for those who work in the field of medicine to draw upon to influence their own discourse. Obstetric discourse in the form of spoken language was gathered from semi-structured interviews with eight practising obstetricians. Results The findings of the analysis suggested that the participants constructed a positive psychological birth experience in varied ways and used multiple rhetorical devices when doing so. The results are reported in two broad categories; the participants’ contrast of ‘obstetric births’ with so called ‘ideal births’ and the use of claims about women’s internal states during labour. The participants’ responses to questions about positive birth experiences were to construct ‘obstetric births’ and ‘ideal births’ in contrast with one another. The births that obstetricians attended were constructed using medical discourse, which emphasised medical complications and medical interventions. This category of birth was presented as a challenging birth type within which to facilitate positive psychological experiences. Obstetric births were contrasted with what were termed ‘ideal births’. Ideal births were described as medically ‘normal’ births that did not require an obstetrician’s intervention. These births were associated with midwifery and presented as a category of birth within which interpersonal relationships between the woman giving birth and the midwife may facilitate a positive psychological birth experience. The rhetorical device of contrasting appears to function here to emphasise difference and key features of obstetric births. The participants made claims about the internal states of women in labour. Internal mental states are not analysed to ascertain whether they are accurate or not within a discourse analysis methodology. Claims were made about women’s experience of pain and anxiety. Such claims are viewed as discursive devices that have certain functions within the discourse. Within this study, inferences about internal mental states appeared to have a possible function to present the women in labour as less able to communicate and difficult to have a discussion with. Communication was presented as a factor that may facilitate a positive psychological birth experience. A function of these claims about internal states may be to construct positive births as difficult to facilitate with women during labour due to their internal mental states. Discussion The results of this analysis are considered in light of discourse analysis theory and the writings of Foucault. Discourse analysis has been described as a ‘theory-method’ because it makes certain claims about how language creates reality (Potter, 1997). Further consideration is given to the appropriateness of applying other psychological theories from Menzies Lyth’s (1960) research into social defences. Suggestions for further research and the possible clinical implications of this study are considered