Woman centred care or institution centred care? A discursive analytic study of childbirth-related decisions

Abstract

This dissertation presents an examination of the ways in which women participate in decisions relating to giving birth in hospitals. The overall aim of the study is to identify and describe aspects of language used to communicate childbirth decisions, since current guidelines promote women’s active involvement in maternity care (i.e., woman-centred care). Specifically, this study aims to contribute to empirical evidence about the ways in which decisions in maternity care are accomplished and understood. The study takes an ethnomethodological approach, framed by discursive psychology (DP) to examine naturally-occurring data. From this perspective, this dissertation presents three articles which together identify and describe aspects of language used to negotiate and communicate childbirth decisions in the context of woman-centred care frameworks. Article one examines online birth narratives for routine ways in which women orient to medical interventions as an accountable matter. Article two illuminates how midwives accomplish the institutional imperative of model of care allocation in interactions between midwives and women. Article three provides an examination of the ways in which decisions are made to plan for an epidural during labour in routine antenatal consultations with midwives. Together, these three articles add to a growing body of knowledge around the ways in which women participate in making decisions in hospitals related to giving birth. Drawing on concepts in DP and using thematic analysis, conversation analysis and membership categorisation analysis, these studies examine how participants oriented to the extent to which women are afforded the authority to control their birthing experience. Drawing on contemporary interactional research which theorises the epistemic and deontic basis of social relations, this study explicates how women’s participation in childbirth-related decisions are described and co-constructed in naturally occurring contexts. The analysis showed that midwife participants oriented to the rights, and indeed responsibilities, of pregnant women to make decisions related to giving birth in a hospital setting. The ways in which women are involved in decisions, however, seem to prioritise the needs of the institution rather than the birth aspirations and preferences of pregnant woman. In this sense, woman-centred care was realised to the extent that decisions were made within the constraints of institutional requirements. The findings contribute to three main areas of research: women’s experiences of childbirth in a hospital setting; the conversation analytic study of institutional interactions; and the respecification of psychological phenomenon as interactional objects within discursive psychology. The ways in which childbirth-related decisions are made and described can shed light on the practical implementation of woman-centred care principles in a hospital institution. Such fine-grained descriptions of authentic accounts and interactions may contribute much needed empirical detail and specification that can be the basis for refining and developing recommendations for practice.