Author Identifier

Kate Buchanan

https://orcid.org/0000-0002-8552-7412

Date of Award

2023

Document Type

Thesis

Publisher

Edith Cowan University

Degree Name

Doctor of Philosophy (Integrated)

School

School of Nursing and Midwifery

First Supervisor

Lisa Whitehead

Second Supervisor

Elizabeth Newnham

Third Supervisor

Sadie Geraghty

Abstract

Background: The maternity system has a complexity of everyday ethical issues. The bioethical principles: non maleficence, beneficence justice and autonomy, that govern health care practice have been criticised as abstract, patriarchal and even rhetorical in maternity care practice (MacLellan, 2014) and consequently may be insufficient in guiding care of childbearing women. Midwifery-led care is guided by the International Confederation of Midwives International Code of Ethics, which considers more than the bioethical principles, such as the importance of relationship. Care ethics is a relational based feminist ethics first described by Gilligan (1983) and has been theorised as an alternate paradigm for midwifery (Newnham & Kirkham, 2019). A paper was published in Nursing Ethics as a result of the literature review; Care ethics framework for midwifery practice: A scoping review and it was determined that care ethics is demonstrated in practice with four domains; Relationship, Context, Caring Practices and Attention to power. In addition, there is limited empirical evidence as to women’s experiences of care from an ethical perspective, and importantly what women describe as ethical, revealing a gap in the literature that has yet to be explored.

Objective: The aim of the study reported in this thesis was to investigate women’s experience of maternity care from an ethical perspective and to determine whether a care ethics paradigm would better suit midwifery.

Methods: The transformative research was undertaken using Feminist Participatory Action Research (FPAR). FPAR is a feminist and transformative research design, which includes participants as central to research design. Purposive sampling was used to recruit women who had experienced midwifery-led care. Nine women formed the Community action research group (CARG), they worked with me over three years, guided the research and planned action. The CARG participated in five focus groups, for data collection and organising action toward the changes they wished to see. Their involvement in the research included: defining the research problem, creating a priori codes for analysis, reviewing analysis, disseminating findings and provided recommendations for policy change. A paper was published in Woman and Birth: Navigating midwifery solidarity: A feminist participatory action research framework, describing some of the finer points of FPAR including a framework for novice researchers. In phase two a further ten women who had had midwifery-led care were involved in this study and interviewed about their experiences of ethical maternity care. Data were collected from September 2019 to April 2022 via five focus group interviews and ten one-on-one semi-structured interviews. The interviews were recorded, and transcribed, and template and Reflexive thematic analysis was applied (Braun & Clark, 2021).

Findings: The findings in this study were presented in two parts. The first phase of the study revealed midwifery-led care demonstrated care ethics in practice. The Community Action Research Group (CARG) created a priori codes and a template analysis determined that midwifery models of care demonstrate care ethics. A paper of these findings was published in Nursing Ethics; Does midwifery-led care demonstrate care ethics? A template analysis.

In the second phase of the study, the data corpus was analysed using reflexive thematic analysis and the primary theme, Radical desires: Individuals’ values and context, captures the woman at the centre of the care, her values and context, as central to understanding ethics. The quality of the relationship, the knowledge that was shared, and the manner of the care given were deemed important elements of ethical care. I assigned categories Woman-centred ethics or Authoritarian ethics to describe these elements of ethical or unethical aspects of care. Woman-centred ethics contains the subcategories of: harmonised relationship, transparent wisdom, and midwifery solidarity. The category Authoritarian ethics contains the subcategories of: uneasy alliance, opaque information, and saving women from themselves. How the woman experienced these categories affected the liminality and sense of self, and are described in subthemes, Claiming power and Surrendered power.

Discussion: The themes were explained, discussed, and contrasted against the extant literature in the discussion. Pregnancy and birth as a transformative rite of passage was valued by the women in this study and they perceived care as more ethical when the care providers respected this. Authoritarian ethics, when viewed with a feminist and care ethics lens highlighted continued female oppression from the maternity system structures and culture. A conceptual model, Woman-centred ethics, was developed based on midwifery philosophy and feminist care ethics, which may help midwives embody a different kind of ethics and provides a way to enhanced ethical practice. A paper was published that shared the conceptual model in Midwifery Journal: Woman-centred ethics: A feminist participatory action research.

Conclusion: This study has contributed to the body of knowledge that describes how women perceive ethics in maternity, and honours women’s voices as central to ethical care. The study advances midwifery philosophy through exploring midwifery ethics and offers a conceptual model to guide practice. The woman-centred ethics model describes an embodied way of practicing ethical care and may provide a starting point for moving the field forward in ethical discussion. The CARG group involvement in the research and action together were an important feature of this project. Several recommendations arose from this study for practice, organisational, and educational processes.

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