Woman - Centered Maternity Nurs

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ACCEPTANCE
This dissertation, WOMAN-CENTERED MATERNITY NURSING

EDUCATION AND THE LIVED EXPERIENCE OF NEW GRADUATES IN
MATERNITY PRACTICE by GLORIA PEEL GIARRATANO, was prepared under the
direction o f the candidate’s dissertation committee. It is accepted by the committee
members in partial fulfillment o f the requirements for the degree o f Doctor o f Philosophy
in Nursing in the School o f Nursing in the College o f Health and Human Sciences,
Georgia State University.
Tommie Nelms, R.N., Ph.D.

Committee Chairperson
Linda McGehee, R.N., Ph.D.

Committee Member
Dorothy HueneClce, Ph.D.

Committee Member
'Ll£L / 'V
William Doll, Jr., Ph.D.

Committee Member /
Date^fy-^^T '3—
QGC)
This dissertation meets the format and style requirements established by the
College o f Health and Human Sciences. It is acceptable for binding, for placement in the
University Library and Archives, and for reproduction and distribution to the scholarly
and lay community by University Microfilms International.
Ju d ith L. Wold, R.N., Ph. D.

rector, College o f Health and Human Sciences
Sherr^ Gaines, R.N., Ph.D.

Acting Director o f Graduate Programs in Nursing
AUTHOR’S STATEM ENT
In presenting this dissertation as a partial fulfillment o f the requirements for an

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G loria Peel Giarratano
ii
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The author o f this dissertation is:
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iii
VITA
Gloria Peel Giarratano
ADDRESS: 1301 Vintage D rive

Kenner, Louisiana 70065
EDUCATION:
Ph.D. 2000 Georgia State University, Nursing
M.S.N. 1979 University o f Alabama in Birmingham,
Maternal-Infant Nursing
B.S. 1977 University o f Southern Mississippi, Nursing
PROFESSIONAL EXPERIENCE:
1984-Present Assistant Professor o f Clinical Nursing

Louisiana State University
1984 Instructor o f Nursing
Nicholls State University
1982-1983 Faculty, Senior Level
Touro Infirmary, School o f Nursing
1979-1982 Instructor o f Nursing
William Carey College
1976-1978 Staff Nurse/Charge Nurse
Jeff Anderson Regional M edical Center
Staff Nurse OB/GYN
PUBLICATIONS:
Giarratano, G., Bustamante-Forest, R., & Pollock, C. (1999).
N ew pedagogy for maternity nursing education. JOGNN: Journal
o f Obstetric. Gynecologic, and Neonatal Nursing. 28. 127-134.
Giarratano, G. (1997). Story as text in undergraduate
curriculum. Journal o f Nursing Education. 36. 128-134.
PRESENTATIONS:
1998 “Getting out from Under-Changing Childbirth Practices in
the Big Easy,” ANA Conference on Nursing Education.
University o f Washington, Seattle, WA, October 21, 1998.
1997 ‘Teaching to Transform Caring Practices in Maternity
Nursing,” 24th Annual Isabel Maitland Stewart Conference
on Research in Nursing; Teachers College Columbia
University, New York, NY, April 18,1997.
PROFESSIONAL SOCIETIES AND MEMBERSHIPS:

1977-Present American N urses’ Association
1977-Present Sigma Theta T au
1979-Present The Association o f W omen’s Health,
Obstetric, and Neonatal Nurses
1993-Present Doulas o f N orth America
1993-Present International Childbirth Education Association
iv
ABSTRACT
WOMAN-CENTERED MATERNITY NURSING EDUCATION AND THE
LIVED EXPERIENCE OF NEW GRADUATES IN MATERNITY PRACTICE
by
GLORIA GIARRATANO
The purpose o f this study was to uncover the meanings o f the clinical experiences
o f registered nurses working in maternity settings subsequent to studying maternity
nursing from a feminist perspective in a generic baccalaureate nursing program. The
focus o f the Heideggerian phenomenologic study was to discover and make visible the
shared practices and common meanings o f the new graduates' practices as maternity
nurses.
Nineteen maternal-newborn nurses between the ages o f 23 and 43 who had been
in practice from six months to three years were interviewed. The semi-structured
interviews focused on the nurses’ descriptions o f their everyday practices as maternity
nurses, the values that guided their practices, and the enabling and/or constraining factors
to providing woman-centered maternity nursing care. A hermeneutical analysis process
developed by Diekelmann and Allen (1989) and a feminist-postmodern perspective were
used to interpret the nurses’ experiences. Lincoln and G uba’s (1985) trustworthiness
criteria and Guba and Lincoln’s (1989) authenticity criteria were employed to assure
methodological rigor. The constitutive patterns identified from the nurses’ stories were:
Otherness, Being and Becoming Woman-Centered, and Tensions to Practicing Woman-
Centered Care. Findings revealed how feminist pedagogy in maternity nursing education
served to raise the nurses’ consciousness to oppressive health care practices, stimulate
woman-centered care through nursing involvement, advocacy and empowerment-

v
building, and affect the experiences o f women in childbirth. The study exposed the
tensions, barriers and facilitators for providing women-centered care in medically-
focused maternity settings. Nursing education and nursing practice recommendations
were made to increase and enhance woman-centered care.
vi
W OMAN-CENTERED MATERNITY NURSING EDUCATION AND THE
LIVED EXPERIENCE OF NEW GRADUATES IN MATERNITY PRACTICE
by
GLORIA PEEL GIARRATANO
A DISSERTATION
Presented in Partial Fulfillment o f Requirements for

the Degree o f Doctor o f Philosophy in Nursing in the School
o f Nursing in the College of Health and Human Sciences
Georgia State University
Atlanta, Georgia
2000
vii
UMI Number 9965338
Copyright 2000 by
Giarratano, Gloria Peel
All rights reserved.
UMI
UMI Microform 9965338
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unauthorized copying under Title 17, United States Code.
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Copyright by
Gloria Giarratano
2000
viii
DEDICATION
This dissertation is dedicated to my husband, Frank, who like the male dolphin in nature,
encircled me, protecting the environment I needed for the labor o f this project. And, to
my parents, Taylor C. Peel and Ada M. Peel who showed me how to face life’s passages
with passion and tenacity.
IX
ACKNOWLEDGEMENTS
This dissertation would not have been possible without the support o f many
people. The dissertation committee that included Dr. Tommie Nelms, Chair, and the
members, Dr. Linda McGehee, Dr. Dorothy Huenecke, Dr. William Doll, and adjunct
member, Dr. Robbie Davis-Floyd helped me find direction, inspiration, and discipline to
complete this study. In individual ways each person on the committee served as a m entor
for research, teaching, and living the life o f a scholar.
I am grateful to Rosa Bustamante-Forest and Dr. Christine Pollock for making our
journey into woman-centered maternity nursing education possible and for supporting me
throughout my doctoral studies. I appreciate the guidance o f Dr. Christine Pollock and
Dr. Joan Sullivan in the data analysis process. The editorial expertise offered by June
Rees and the transcription services o f Kim Perrot were invaluable to the completion o f
this project. I also thank my many colleagues at Louisiana State University Health
Sciences Center who encouraged me with their humor, support, and acts o f kindness.
I wish to thank the nineteen m atemal-newbom nurses who participated in this
study. Only through the nurses’ commitment to the care o f women and babies is woman-
centered practices possible.
TABLE OF CONTENTS
Page
List o f T ables..........................................................................................................................xviii
List o f Abbreviations...............................................................................................................xix
Chapter
I. Introduction.....................................................................................................................1
Focus o f Inquiry.............................................................................................................. 1
Background o f the S tudy............................................................................................... 5
Background o f the Researcher.....................................................................................11
Assumptions Related to the Phenomena o f Concern.............................................. 42
Statement o f Purpose................................................................................................... 44
Selected Method and Justification for its Potential................................................. 44
Significance o f the Study to N ursing.........................................................................47
Sum m ary........................................................................................................................49
II. Context o f the Study.................................................................................................... 51
Theoretical Context......................................................................................... 53
Introduction: Feminism and Postm odernism .................................53
Contemporary Fem inism s....................................................55
Liberal Fem inism .....................................................58
Cultural Fem inism ...................................................59
Socialist Feminism.................................................. 60
Psychoanalytic Fem inism ...................................... 61
Radical F em inism ....................................................61
xi
Chanter Page
Postmodernism....................................................................................62
Power Relations in the Postmodern:

Michel Foucault.................................................................... 64
The Awkward Pairing: Feminism and Postm odernism ............... 68
The Possibilities o f a Feminist-Postmodern

Constellation..........................................................................69
Critics o f a Feminist-Postmodern Constellation.............. 71
Feminist Interpretations o f Foucault’s Postmodern

P ow er...................................................................................... 73
Woman as O th er....................................................................74
Feminist/Postmodern Critique as Resistance to

Childbirth Practices............................................................... 77
Sum m ary.............................................................................................. 82
The Feminist Health Movement: A Call for

Woman-Centered Care.......................................................................83
Philosophy o f Woman-Centered C a re ...............................91
Operationalization o f W oman-Centered C a re ................. 95
Co-Option o f Woman-Centered C are.............................. 101
Cultural Analyses o f Western Birth P ractices............................. 103
Social Control o f Birth........................................................103
Authoritative Knowledge o f B irth....................................105
Technocratic B irth.............................................................. 106
Social Movements for Changing Technocratic Birth Norms ... 111
World Health Organization................................................111
Coalition for Improving Maternity Services (CIMS) ...114
xii
Chapter Page
The Doula Movement: Doulas o f North America

(D O N A )................................................................................115
Renaissance o f M idw ifery.................................................116
Sum m ary............................................................................................ 119
Nursing and Fem inism .....................................................................120
Nursing: Feminist Roots and the Patriarchy.................. 120
The Resurgence o f Feminism: A Call for Critical

Consciousness in N ursing.................................................124
Postmodernism within Nursing......................................... 126
Sum m ary............................................................................................ 128
M aternity N ursing.............................................................................128
Historical Roots in O bstetrics........................................... 129
External Forces that Impacted Maternity N ursing 133
The W omen’s Health M ovement.........................133
The Technology R evolution.................................138
The Managed Care Environm ent.........................139
Discourses Reflected in M aternity Nursing Texts 140
Educational Theory and Women-Centered M aternity Nursing

E ducation............................................................................................142
Patty Lather...........................................................................144
Maxine G reene..................................................................... 147
William P inar........................................................................150
Educational Theory and Implications for the S tudy................................. 153
Sum m ary.......................................................................................................... 154
xiii
Chapter Page
Nursing Research C ontext........................................................................... 155
Implications o f Research Context to this Study........................................161
Chapter S um m ary.......................................................................................................163
III. The Research P ro cess.................................................................................................165
Overview....................................................................................................................... 165
Statement o f P urpose..................................................................................................165
M ethodology................................................................................................................ 166
Setting............................................................................................................................174
Participants................................................................................................................... 176
Data Generation S trategies.......................................................................................178
Diekelmann and Allen’s Hermeneutical Process o f A nalysis............................ 181
Trustworthiness........................................................................................................... 184
C redibility.......................................................................................................185
Transferability................................................................................................ 188
Confum ability................................................................................................ 188
Authenticity C riteria...................................................................................................189
Protection o f Human Participants.............................................................................191
Summary....................................................................................................................... 192
IV. Research Process......................................................................................................... 193
Participant R ecruitm ent..............................................................................................193
S etting........................................................................................................................... 199
xiv
Chapter Page
Generation o f Data: The Interview Process........................................................... 202
Data A nalysis.............................................................................................................. 205
T rustworthiness...........................................................................................................208
C redibility................................................................................................................... 208
T ransferability.............................................................................................................212
Confirmability.............................................................................................................213
Authenticity C riteria..................................................................................................213
Protection o f Human Participants............................................................................218
Sum m ary......................................................................................................................219
V. Findings and Discussion........................................................................................... 220
Description o f Participants........................................................................................220
Findings........................................................................................................................ 223
Constitutive Pattern: Otherness...................................................................225
Theme: The Maternity Course: The Opening o f a Whole

Other Light........................................................................................227
Theme: The Negative Attitude about the Course: I Didn’t

Agree with T h e m .............................................................................231
Theme: O ther Nurses would not have Done T h a t......................233
Constitutive Pattern: Being and Becoming a Woman-Centered

N urse............................................................................................................... 240
Theme: Developing a Philosophy................................................. 242
Theme: Putting the Whole Package T ogether............................ 255
Constitutive Pattern: Tensions in Practicing Woman-Centered C are...273
Theme: Temporality: A Time to be B o m .................................... 276
XV
Chapter Page
Theme: Woman-Centered Care in a Medically Focused

Environment.....................................................................................281
Theme: Relationships..................................................................... 292
Sum m ary..................................................................................................................... 303
VI. Conclusions and Recomm endations...................................................................... 304
Conclusions and D iscussion...................................................................... 304
Creators o f Woman-Centered C are.............................................. 305
Barriers to Practicing Woman-Centered C a re ........................... 308
Advocacy as Woman-Centered C are........................................... 313
Facilitators to Practicing Woman-Centered C a re ......................314
Resistance to Feminist-Postmodern Pedagogy.......................... 316
Assumptions...................................................................................................318
Theoretical Context o f the Study............................................................... 328
Feminist-Postmodern Theory.........................................................328
The Culture o f Childbirth............................................................... 331
Maternity Nursing as Praxis........................................................... 332
Liberatory Education Theory......................................................... 332
Personal Experience with the S tudy.......................................................... 334
Recommendations for Nursing Education, Practice, and Research 337
Nursing E ducation...........................................................................337
Nursing Practice............................................................................... 339
Nursing R esearch.............................................................................341
Sum m ary...................................................................................................................... 345
xvi
Chapter Page
C onclusion..................................................................................................................345
References...................................................................................................................347
Appendices..................................................................................................................3 84
Appendix A Letter to Participants..............................................................384
Appendix B Consent F orm ........................................................................385
xvii
LIST OF TABLES
Table Page
1 Age Distribution o f Participants................................................................................220
2 Length o f Employment in Matemal-Newbom Practice......................................... 221
3 Constitutive Patterns and Themes............................................................................. 224
xviii
LIST OF ABBREVIATIONS
ACNM American College o f Nurse-Midwives
ACOG American College o f Obstetricians and Gynecologists
ASPO American Society for Psychoprophylaxis in Obstetrics
AWHONN Association o f Women’s Health, Obstetric, and Neonatal
Nursing (formally NAACOG)
BSN Bachelor o f Science in Nursing
CIMS Coalition for Improving M aternity Services
CM Certified Midwife
CNS Clinical Nurse Specialist
CPM Certified Professional Midwife
DONA Doulas o f North America
EFM Electronic Fetal Monitor
FCMC Family-Centered Maternity Care
FWHC Feminist W omen’s Health Center
ICEA International Childbirth Education Association
IRB Institutional Review Board
LDR Labor-Delivery-Recovery
LDRP Labor-Delivery-Recovery-Postpartum
LSUMC Louisiana State University Medical Center;
(Currently known as Louisiana State University Health
Sciences Center)
MANA Midwives Alliance o f North America
NAACOG Nurses’ Association o f the American College
o f Obstetricians and Gynecologists

xix
NICU Neonatal Intensive Care Unit
NIH National Institutes o f Health
NARM North Am erica Registry o f Midwives
ORW H Office o f Research on Women’s Health
VBAC Vaginal Birth A fter Cesarean
WHM W omen’s Health Movement
WLM W omen’s Liberation Movement
WHO World Health Organization
XX
CHAPTER I
INTRODUCTION
Focus o f Inquiry
Traditional models o f childbirth care that are founded on patriarchal values o f
m odem Western culture, are believed to exert power over nursing practices and define,
control, and limit w om en’s maternity experiences and reproductive options (Amey, 1982;
Davis-Floyd, 1992; Jordan, 1997; Rotham, 1982; Sandelowski, 1981, 1984; Wilson,
1996). In order to em power future nurses to transform traditional childbirth practices, it is
essential to raise their critical consciousness and enable their understanding o f dominant
medical discourses, thereby sensitizing them to the social, political, and cultural variables
impacting women’s healthcare (Cheek & Rudge, 1994a; Taylor & Woods, 1996). Nurses’
comprehension o f the context o f women’s healthcare experiences is fundamental in
working toward a gender-sensitive healthcare system where women can “thrive rather
than merely survive” (American Academy o f Nursing, Writing Group o f the Expert Panel
on W om en’s Health, 1996, p. 7) in healthcare environments throughout the stages o f life.
A feminist, o r woman-centered, philosophy o f care is thought to recreate
w om en’s traditional healthcare experiences by shifting power and knowledge from the
caregiver to the woman/client (Andrist, 1997a; Cassidy-Brinn, Homstein, & Downer,
1984; Ruzek, 1978; Sherwin, 1998; Taylor & Woods, 1996). In a woman-centered model
o f childbirth, caregivers share power, decision-making, and healthcare inform ation with
the woman. The pow er o f a medically-focused discourse is decentered by a
2
woman-focused discourse concerned with comprehensive healthcare needs that address
wom en’s multifaceted life circumstances. Women-centered care has the potential to offer
other experiences in healthcare that are unavailable within traditional models o f care.
M aternity practices that support woman-centered care respect the diversity and intricacy
o f wom en’s lives with the awareness that there is no one ideal maternity experience and
no generic woman.
The possibility o f women gaining access to other childbirth experiences requires
social transformation at many levels. The current healthcare system can only be
transformed to a woman-centered model through social change and activism (James,
1996; Taylor & Woods, 1996). The role and traditional practice that maternity nurses
employ as caregivers for women in community and hospital settings must be challenged
and recreated to effect social changes in women’s healthcare. Benefits o f family-centered
principles are overshadowed by conventional maternity nursing that supports uncritical
routine medical intervention and technology, and is inadequate for regenerating birth as a
woman-centered experience (McKay, 1991; Morgan, 1998; Olson, 1999).
The maternity nurse who is poised to transform healthcare delivery for women
must be critically aware o f the political and social power relations impacting the
maternity event. This requires a major change in present maternity nursing education.
Such a shift will enable nurses to recognize the power and limitations o f dominant
medical models, and envision new care possibilities. The incorporation o f feminist and
postmodern perspectives uncovers layers o f cultural and social structures presently
defining birth experiences and nursing practices (Adams, 1994; Bordo, 1993; Davis-
Floyd & Sargent, 1997; Luke & Gore, 1992; Michie & Cahn, 1997; Wicke & Ferguson,
1994). Feminist pedagogy expands maternal nursing study and prepares future nurses to
3
value the woman-centered philosophy and social activism necessary to change women’s
maternity experiences (Henderson, 1997; Varcoe, 1997). Feminist nursing education that
aims to empower maternity nurses to support woman-centered perspectives, philosophies,
and healthcare practices is rarely documented in core maternity curriculum (Breslin,
1995).
Nurse educators in women’s health courses reported powerful experiences using
feminist approaches to educate nurses in consciousness o f social oppression o f women,
and the value o f woman-centered healthcare (Andrist, 1997b; Boughn, 1991; Boughn &
Wang, 1994; Hezekiah, 1993; Thomas, 1992; Valentine, 1997). Yet, the long-term
impact o f feminist pedagogy on nursing practices, and healthcare experiences o f women,
remains unknown. Practices and values o f maternity nurses, who were taught a feminist
perspective in nursing school, required study.
The purpose o f this study was to dialogue with graduates o f a generic BSN
program concerning their experiences as registered nurses working in maternity settings,
subsequent to studying a woman-centered philosophy o f care in an undergraduate
maternity nursing curriculum. Semi-structured conversations focused on the new
graduates’ descriptions o f their everyday practices as maternity nurses, the values guiding
their practices, and the enabling and/or constraining factors that impacted their practices.
Heideggerian phenomenological methodology was used to reveal shared practices and
common meanings from the nurses’ descriptions o f lived experiences in maternity
nursing (Cohen & Omery, 1994). The prim ary aim o f phenomenology, as a human
science, is to achieve a deeper understanding o f the nature and meaning o f everyday
experiences. With the use o f Heideggarian research methodology, I described the essence
o f lived experience within the context o f the nurses’ experiences, and unraveled
4
significance through hermenutical interpretation. Fem inist theory was used as a lens to
interpret cultural messages o f oppression that were revealed in the nurses’ experiences as
caregivers o f women in patriarchal environments.
As the researcher, I listened for how the new nurses integrated what was learned
about woman-centered care in the undergraduate m aternity nursing course with the
realities o f practice. Tensions new graduates experienced in assimilating woman-centered
care into the reality o f practice were revealed w ithin the context o f their clinical
experience. I also explored the consequences to their professional roles and personal lives
o f learning and practicing woman-centered care.
Research with maternity nurses, who were taught woman-centered ideology in
their undergraduate maternity nursing curriculum, illuminated the meaning this ideology
had on their nursing practice, and personal lives. T he impact feminist ideology had on
maternity practice was described through lived experiences o f new graduates. This study
addressed the need to closely examine nurses’ experiences in institutions and situations
where woman-centered philosophy was not embraced. Resultant knowledge o f new
graduates’ tensions and coping strategies can inform nursing faculty on how to prepare
students to deal with practice reality that is antithetical to woman-centered care. Factors
that facilitated or limited the ability o f graduates to act as role models, change agents, and
affect resolution o f conflicts arising from their philosophy o f care were explored. Nursing
service managers, educators, and clinical preceptors can Iearn about barriers and tensions
facing graduates who implemented woman-centered care. Nursing service educators and
managers can plan strategies to overcome identified barriers to woman-centered care
practice, and they can offer further support for gender-sensitive healthcare delivery.
5
Background o f Study
Nursing care in current maternity practice, centers on obstetrical medical practices
that emerged in the twentieth century. Davis-Floyd’s (1990, 1992, 1994, 1996) cultural
analyses o f human birth experience in modem Western culture describe a technocratic
model o f childbirth that justifies routine medical rituals such as continuous IV fluids,
fasting, electronic fetal monitoring, delivery in the lithotomy position, episiotomies,
immobility, wearing hospital clothing, cervical dilation checks, epidurals, and coached
pushing. Onset and progress o f labor is often medically controlled by “ripening” the
cervix with topical medication, rupturing membranes, and infusing IV pitocin. Benefits,
risks, and consequences o f this medical model o f care are debated in medical, nursing,
and consumer literature (Albers & Savitz, 1991; American College o f Obstetricians and
Gynecologists, 1995; Aim s, 1994; Enkin, Keirse, Renfrew, & Neilson, 1995; Garite,
1994; Goer, 1995; Nathanielsz, 1994; O ’Reilly, Hoyer, & Walsh, 1993; Roberts &
Woolley, 1996; Simpson, 1996).
Controversy centers on the meaning o f medical intervention in low-risk, normal
pregnancies (Albers et al., 1997; Albers & Savitz, 1991; Blais et al., 1994; Bloom et al.,
1998; Wagner, 1994). It is a concern that many routine obstetrical interventions are
potentially harmful. Evidence-based research indicates most routine interventions carry
inherent risks. F or example, epidural anesthesia is associated with increasing cesarean
births in nulliparas (Thorp et al., 1993; Thorp & Breedlove, 1996). In a study by Shiono,
Klebanoff, and Carey (1990), women with midline episiotomies were 50 times more
likely to have a third or fourth-degree laceration, compared to women with no
episiotomy. Since its inception, continuous fetal monitoring is associated with a rise in
cesarean births, w ith no substantial benefit documented for low-risk women (Banta &
6
Thacker, 1979; Prentice & Lind, 1987; Sehgal, 1981). Despite an overall decline in
cesarean rates, the National Center for Health Statistics 1997 report reveals the incidence
o f women giving birth by cesarean section remains at 20.8%, with southern states, such
as Louisiana (25.4%) and Mississippi (26.7%), exceeding the national average (Ventura,
Martin, Curtin, & Matthews, 1999).
Historically, after the medical profession discredited midwives in the early
twentieth century, maternity nurses acted in compliance with patriarchal care models.
Modem nursing-care rituals compliment doctors’ medical intervention and serve to
institutionalize maternity experiences during hospital births. Today, nurses are caught in
a position o f implementing many o f these routines, and/or providing nursing care
associated w ith these controversial medical interventions (Amey, 1982; Leavitt, 1986).
The first significant reform in hospital-based maternity practices, from the1960s
through the 1970s, was sparked by a consumer/women’s health movement seeking
humanizing birth practices and family-centered care (Wertz & Wertz, 1989). Nurses lead
the way by redesigning hospital settings and revising hospital policies to focus on
childbirth as a family-centered event (McKay & Phillips, 1984). Those changes resulted
in more comfortable and esthetic physical changes, and enhanced family involvement.
Critics o f the reforms called them cosmetic changes. With advancing technology, medical
control o f the childbirth environment actually increased (Amey, 1982; M cKay, 1991).
The goal to humanize birth during this reform movement was greatly thwarted by
an explosion o f technology, continued medical rituals, and increased epidurals and
cesarean sections (Armstrong & Feldman, 1990; Davis-Floyd, 1990; Kitzinger, 1994;
Odent, 1992; Olson, 1999; Rothman, 1982; Wagner, 1994). Prenatal classes were
denounced for preparing women/families for routine medical practices rather than
7
empowering wom en to voice their choices from many possible alternatives (Nichols,
1993; Zwelling, 1996).
Today, physicians delegate the use o f obstetrical technology, such as
matemal/fetal electronic monitoring, to nurses, thus transferring medical practices to the
work o f nursing (Sandelowski, 1996a). Meanwhile, nurses struggle with changes in the
delivery o f humanistic care. Technologically focused assessment replaces touch and
promotes the b elief that care improves just because o f available technology. Parallel to
this line o f thinking, society assumes that technology could guarantee a perfect baby, thus
setting up a litigious atmosphere between families and caregivers. Consequently,
obstetrics is a high-risk area for legal liability when problems result from birth, or a
perfect baby is not produced (Hawthorne & Yurkovich, 1995; Phillips, 1988;
Sandelowski, 1989).
Since 1985, the World Health Organization (WHO) has organized perinatal
consensus groups to study the impact o f W estern birth technology on medical and social
outcomes o f birth (Wagner, 1994). In 1996, W HO convened a group from each region o f
the world to review evidence based research concerning Western medical practices
during birth. This delegation supported discontinuance o f many care rituals during
normal birth. Approximately twenty-five United States’ matemal/child organizations and
professionals formed a group, the Coalition for Improving Maternity Services (CIMS)
(1996), in step w ith WHO’s 1996 recommendations to improve the birth environment.
Two o f the organizations that represent nursing include the Association o f W om en’s
Health, Obstetrics, and Neonatal Nursing (AWHONN) and the American College o f
Nurse-Midwives (ACNM). M any o f WHO’s suggestions were incorporated in CEMS’
“Ten Steps o f the Mother-Friendly Childbirth Initiative.”
8
Many o f the harmful routine interventions the coalition recommended stopping
were those that nurses commonly carry out as standard practice, as supported and/or
ordered by physicians. The coalition’s advice to provide mother-friendly care focused on
reeducating caregivers in basic care practices, outside o f a medical intervention model.
For example, step seven directed staff to be educated in “non-drug methods o f pain
relief," and to refrain from promoting the use o f analgesic or anesthetic drugs “not
specifically required to correct a complication." The care initiatives charged maternity
nurses, as primary caregivers during labor, to reevaluate their values and the skills
necessary to care for women outside o f a medical intervention model.
The women’s health movement, founded on feminist values, called for a woman-
centered model o f care. This model w ould change the way healthcare is delivered to
women, thereby contributing to the social transformation o f women. Woman-centered
care models seek to provide holistic healthcare approaches that em power women and
acknowledge the relational needs and social stresses that impact w om en’s experiences
(Andrist, 1997a; Cohen, Mitchell, Olesen, Olshansky, & Taylor, 1994; Ruzek, 1978;
Sherwin, 1998; Surrey, 1991). An optim al woman-centered model o f practice links
childbearing to the w om an's health throughout the life span rather than isolating it as a
separate event. Ideally, the woman is an active participant in m aking informed choices
(American Academy o f Nursing, Writing Group o f the Expert Panel on W omen’s Health,
1996; W alker & Tinkle, 1996).
The midwifery model o f care, commonly practiced by nurse midwives, is
consistent with the goals o f the women’s health movement, although feminist ideology is
not always cited (M cCool & McCool, 1989; McLoughlin, 1997). M idwife, meaning
“with woman,” is inherently woman-centered, in contrast to obstetrics, m eaning
9
“standing before” women (Phillips, 1996,2). Goals of midwifery are to support the
woman in her childbirth experience, enabling empowerment and discovery o f inner
strength to give birth. Holistic practices that unify mind, body, and spirit are common.
The midwifery model o f childbirth is woman-centered, and often referred to as such
(Dwinell, 1992; Expert M aternity Group, 1993; Rooks, 1997).
Reconceptualizing maternity nursing practices with a woman-centered care
philosophy includes becoming aware o f how hegemonic discourses o f medicine, science,
and religion exert power over nursing practices and define, control, and limit wom en’s
maternity experiences and reproductive choices (Doering, 1992; Kahn, 1995; Martin,
1992; Treichler, 1990; Weedon, 1997). A change in maternity nursing practices must
begin with conscious awareness o f these hegemonic discourses. According to Andrist
(1988, 1997a), nurses’ perspectives on women, healthcare delivery for women, and the
role o f nursing care in society, m ust be reframed within a feminist philosophy. Nurses
must be willing to change their individual practices to reflect a philosophy o f women-
centered care. Taylor and W oods (1996) call for nurses to become empowered and skilled
advocates for woman-centered care, challenge indiscriminate intervention, and promote
an environment wherein women are empowered to seek equal partnership with the health
professional. Social activism is required to critique and transform traditional practices,
and reeducate women in the possibilities o f healthcare (Andrist, 1988).
Recently, the nursing profession has been more conscious o f its own history o f
oppression and paternalist educational and practice traditions (Ashley, 1976; Bevis &
Murray, 1990; Dickson, 1992; Reverby, 1989). Nurse scholars introduce feminist and
critical theory as alternative philosophies to emancipate and transform nursing practices
(Chin & Wheeler, 1985; Mason, Backer, & Georges, 1991; Sampselle, 1990; Thompson,
10
1987). Central to the purposes o f the reform movement in nursing education, know n as
the “curriculum revolution,” was cultivating a sense o f social responsibility to em power
future nurses to transform healthcare (Moccia, 1987; Tanner, 1990, 1992). M any
educators recognize that educating for social responsibility requires a curriculum that
connects the study o f nursing to personal self-awareness and lived experiences. Nurse
scholars recommend nursing curricula be grounded in phenomenological and caring
perspectives that honor student-centered learning, and women’s ways o f knowing
(Belenkey, Clinchy, Goldberger, & Tarule, 1986; Bevis & Watson, 1989; Dickelmann,
1988, 1989; Nelms, 1990).
Likewise, feminist pedagogy is a stimulus for development o f critical
consciousness, social responsibility, and emancipatory actions essential to nursing praxis
(Bent, 1993; Chapman, 1997; Hedin & Donovan, 1989; Qwen-Mills, 1995). Pedagogy,
founded on the liberating goals o f radical feminism, seeks to expose social injustices
toward women resulting from a society formed by masculine values (Kenway & Modra,
1992). Grounding maternity nursing education in feminist pedagogy enables the nursing
student to recognize that medically-based childbearing experiences are historically
defined by men, and often oppressive to women (Leavitt, 1986; Martin, 1992). Fem inist
knowledge exposes patriarchy’s creation o f women’s nature and body as ‘“ other than’
and often ‘inferior to’ . . . constructed as objectified others, objects o f study for the
knower, critically identified as the enlightened, white-skinned, bourgeois ‘man o f
science’” (Lykke, 1996, p. 4). Feminist enlightenment with postmodern critical
perspective, unmasks dualism inherent in modem societal discourses such as
man/woman, science/nature, self/other (Marshall, 1994).
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Feminist pedagogy provides a critical framework on which to teach nursing
students to critique the healthcare system for gender sensitive goals. Feminist education
supports the goals o f The National League for Nursing’s (1993) Vision for Nursing
Education, which calls for the “incorporation o f critique o f the current health care system
and an analysis o f the present and future health needs o f the population as the basis for
transforming the health care system” (p. 12). The emancipatory potential o f feminist
pedagogy lies in the possibility o f maternity nurses coming to value woman-centered care
and serve as activists to promote woman-centered models o f care.
Background o f the Researcher
Researching lived experience occurs w ithin hermeneutical interpretation o f
narrative text, where the shared meanings o f the authored text and the researcher become
explicit through what Gadamer calls a "fusion o f horizons." Hermeneutics requires the
interpreter to be conscious o f prejudices that constitute being and to reflect upon those
prejudices during the process o f interpretation. The researcher must transcend the
prejudices that underlie the aesthetic, historical, and hermeneutical consciousness.
G adam er (1977/1990) discusses the "positive concept o f prejudice," (p. 151) in his
awareness that not all prejudices necessarily distort the truth. Gadamer (1977/1990) states
that "prejudices are biases o f our openness to the world. They are simply conditions
w hereby we experience something —whereby what we encounter says something to us”
(p. 152). My consciousness as a woman, nurse, and nurse educator serve as open sites
w hereby I continue to encounter and interpret new experiences within the temporal,
historical, and linguistic meanings o f being a person.
I share the context o f my life experiences and prejudices embedded in this study
through my autobiography. In the words o f Carolyn Heilbrun (1989), to write a wom an’s
life “the woman herself may tell it, in what she chooses to call an autobiography.. .or the
woman may write her own life in advance o f living it, unconsciously, and without
recognizing or naming the process” (p. 11). In describing these two possibilities,
Heilbrun challenges the woman writing autobiography to be truthful —to give other
women an account o f life that fairly represents reality o f being a woman. As a literary
critic, Heilbrun finds that lack o f truth in women’s autobiography perpetuates m yths
about women’s lives and does little to show how successes, adversity, and risk-taking in
the public sphere affect women’s lives.
Writing autobiography in shades o f truth forces me to face the unconsciousness
that is part o f my life. What was so unconscious that was written in advance of living
came to me by way o f being bom in a certain place, time and gender. The naming and
becoming conscious o f m y past then becomes part o f my autobiography. Writing truth
into autobiography depends on my success to reveal m yself as a woman whose
achievements were marked by making decisions and choices often accompanied by much
pain. This demands that I write to link and blend the public and private spheres and share
the unconscious parts that were lived out without question, naming what happened.
M y autobiographical text reflects a stream o f scholarship that emerged in the
curriculum field to describe relationships among “school knowledge, life history, and
intellectual development in ways that might function self-transformatively” (Pinar,
Reynolds, Slattery & Taubman, 1995, p. 513). Reclaiming the individual in the public
world o f curriculum and expressing the gendered self within teaching and cuniculum are
revealed through autobiographical discourse (Grumet, 1988; Pinar, 1994). Expressing
m yself through autobiographical scholarship I expose four threads that when woven
together, place this research study within my life perspective as a woman, nurse and
13
teacher. These threads are expressed as: Nurse-nurse teacher: Becoming what is
expected; Nurse-nurse teacher: Writing a new story; Transforming maternity care:
Feminist friendship; Finding mother/being mother.
Nurse-nurse Teacher: Becoming W hat is Expected.
Bom a woman in rural Mississippi in the 1950s to a white, middle class, working
family, it was only natural that I imagined and found the path to become a nurse. The
significant women in m y life, my m other and two aunts, worked in nursing roles. Women
I observed with authoritative status were either nurses or teachers. Others encouraged me
to be a teacher, but in the end I chose nursing. I wanted adventure —to leave the culture I
grew up in, freedom to move geographically, and work as a single woman, being self-
sufficient. I thought nursing might offer more possibilities for independence. Like many
other women choosing careers in the early 1970s, I narrowed the possibilities into what
women had a history o f being successful doing, such as nursing. I also had an academic
side that enjoyed studying the sciences, literature, and history. One thing I knew: I was
not interested in marriage, babies, and a life o f status quo. Although I celebrated
marriages and births with friends, I perceived too much closure associated with these life
experiences.
M y identity with nursing began as a practical and academic one. It was an
acceptable career; and it afforded m e an academic experience o f being educated to be a
nurse. I am part o f a generation o f young women who I believe would have never
considered becoming a nurse without nursing education being situated in higher
education. I attended and graduated from the University o f Southern Mississippi at the
age o f 21. As a young student who experienced nursing education, I struggled with the
human side o f nursing. I struggled to become comfortable with the clinical care role —the
14
fear o f the responsibility and unpredictable circumstances and my shy nature were issues
that kept me wondering in school if I would ever like this. Public health and maternity
nursing were the only two areas I rem em ber enjoying in the experience o f nursing
education.
My first job from 1976 to l9 7 8 was on a 30 patient gynecology unit in a
community hospital in Meridian, Mississippi. I mastered the nursing routines in about six
months and eventually came to enjoy w hat the nursing experiences afforded me. But the
adventure I sought came in ways I d id not expect. I found meaning as a nurse through
experiences such as being with a young woman/birthmother relinquishing her child,
being with young and elder women dying from cancer, and rescuing a woman from shock
whose doctor refused to believe me. T his is when I first encountered women being
victimized in health care. I remember m ore mature nurses who worked with me
commenting on the large numbers o f wom en scheduled for hysterectomies, making
statements such as, “There can’t be another uterus left out there to be removed.” Now
that I am aware o f the history o f w om en’s health care in the 1970s, I understand how I
participated in an era highly criticized for overuse o f hysterectomy. I was the evening RN
who provided the post-operative care, assessments, pain management, and antibiotics. It
was not uncommon for me to have 5-6 new post-operative patients each evening. But the
one case I have never forgotten was a woman, a gravida IV, who came in for a scheduled
tubal ligation for sterlization, but left without having the surgery. Her husband changed
his mind and refused to sign the consent. I remember being in the room with them as she
cried and begged him to sign it. She apologized to m e as if I had been inconvenienced. I
felt terrible for her as we packed up her things. I had no idea how to comfort her. I had
never thought about what it would m ean not to have control over one’s body. Roe v.
15
W ade was decided when I was a senior in high school and with the availability o f birth
control pills, I was unaware that women were still unable to make reproductive decisions.
I knew what happened to this woman was wrong and I was glad not to be in her position.
1 personalized this experience by thinking I would never marry someone like that!
After 18 months o f practice I returned to academia, where I have since remained.
In 1978 I enrolled in the University o f Alabama graduate school in the Clinical Nurse
Specialist (CNS) track in Matemal-Newbom Nursing. This was the only CNS track
available to study w om en’s health care issues. Consistent with the health care system
during that time, to study health care for women, you entered through the woman’s
reproductive organs.
I attended a few class sessions before I caught on that “CNS” did not mean
“central nervous system.” When I realized that the Clinical Nurse Specialist (CNS) role
in maternal-infant nursing meant I would be an advanced practice nurse prepared in
educational, administrative, and clinical expertise surrounding women and babies, I was
compelled to study clinical maternity nursing. In 1979 this meant learning the new
technology equated with being a caregiver in obstetrical nursing. I studied maternal-fetal
electronic monitoring, fetal stress testing and genetic testing. Concepts such as maternal-
infant bonding and family-centered care were fresh and faculty encouraged scientific
research to support changes in the care routines that separated the fam ily at birth. I
learned about the emerging field of infertility. 1 planned teaching sessions at the public
teaching hospital for groups o f women/babies and did case follow-up w ith a few families
in an inner-city housing development. I conducted what turned out to be a timely research
project “measuring” self-esteem o f women who experienced an unexpected cesarean
16
birth. The national trend toward increased cesarean birth rate was ju st beginning in 1978-
1979.
As I got closer to selecting a practice role in which to concentrate, I chose the
nursing education role and worked with an associate degree maternity faculty. M any
Southern states had set 1980 as a target date for having all nursing faculty Master’s
prepared and several nurse recruiters contacted me about positions. I prepared for this
role, by taking two nursing education courses. One course focused on curriculum
development in a program o f nursing and the other on classroom planning and teaching
strategies. These courses prepared m e well for the role I was expected to assume as a
nursing teacher in higher education.
In my first nursing education job I found m yself as the only maternity faculty in a
small private, Baptist College, W illiam Carey College. The main campus was at
Hattiesburg, M ississippi but the baccaulearate nursing school was located at what was
then Southern Baptist Hospital, in N ew Orleans, Louisiana. I moonlighted as a RN in
labor and delivery on the weekends and taught nursing students during the week. The
school had received a federal grant to develop nursing curricula into a modular self-study
format. I worked alone writing modules/units o f “independent” study, which guided
learners through the entire maternity nursing curriculum.
This task followed me to a subsequent teaching job “down on the bayou” in
Thibodaux, Louisiana, where I was hired to plan and write a structured maternity course
syllabus for the opening o f a new Baccalaureate Degree Program at Nicholls State
University. I prepared the syllabus to guide classroom and clinical study, but I never
taught the course. Instead, in fall 1984,1 took a position at Louisiana State University
Medical Center, New Orleans. Five years into teaching nursing in higher education, and
17
before the age o f 2 7 ,1 had become a master at curriculum development in maternity
nursing education.
Between the week I interviewed for the position at LSUMC and the week I started
the faculty voted to revise the curriculum. This revision entailed a major re-writing o f all
course syllabi with a programmed, behaviorist design that included writing objectives and
detailed content outlines for every lecture/class topic in the course. This was not good
news to me —by now curriculum “work” as I had come to know it was getting repetitious
and boring. I opened my file cabinet and pulled out the previous two syllabi I had written
and shared those with the maternity faculty, which moved us along a bit faster. For the
first time I worked with a group o f maternity faculty with a common interest. But I was
also assigned to assist writing other course syllabi— Foundations o f Nursing and Nursing
Management. With my course organizational skills down, I was asked to coordinate the
first course o f this “new” curriculum, Foundations o f Nursing Practice. I still have a gift a
peer gave me that semester, referring to me as “the producer,” because orchestrating the
groups o f students, faculty, and multiple labs/equipment was worthy o f an academy
award! I performed these tasks quite well and was rewarded with more o f the same.
Second to curriculum development in nursing education came the actual teaching
(which was believed to be heavily dependent on the quality o f the syllabus and the
teacher’s ability to follow the syllabus). My teaching style was developed through
modeling the nurse educators who had taught me and observing other faculty peers.
Lecturing was the expected format for teaching. Soon I became a master o f the controlled
classroom. I had the ability to get as much content across in a short a period o f tim e as
anyone. For example, I taught all m ajor conditions o f high-risk pregnancy in two hours. I
assumed if students knew the content I outlined on the stack o f transparencies, they
18
would possess the nursing knowledge required to care for w om en in these situations. This
teaching format came with an unwritten contract with the students: expect this content to
be emphasized on the exam. I f this did not happen, the teacher had to deal w ith students’
anger and their dislike o f the faculty and/or course. There were alarms that occasionally
went o ff with this focus o f teaching content. For example, when I also spent tw o hours
lecturing on the psychosocial problems common to women/families experiencing high
risk pregnancy, som e classes were turned o ff to this “soft” content, preferring more
lecture on the medical care o f the conditions. Lecturing was inadequate in helping the
novice student to appreciate the social and relational needs o f women experiencing-
pregnancy crisis. N ot knowing what else to do, I asked other faculty peers who had
experienced health problems during pregnancy to come to the classroom and share
personal experiences.
I tolerated classroom teaching, finding more meaning in the clinical education o f
students. I helped students do what I needed most when I was a young nursing
student.. .to enjoy the practice, while learning. I worked to teach and assist students to
learn without using extreme tactics o f intimidation and fear. Faculty were expected to
grade clinical performance at LSUMC, so that served as adequate intimidation. In
becoming more self-aware o f m yself as teacher, I now realize that I kept a level o f
detachment from the students in many cases, not always giving enough attention to their
personal lives and experiences as they studied nursing. This kept students from seeking
me as a resource when professional or personal problems impacted their learning. This
detached relationship often prevented me from giving o f myself, as teacher.
My focus was teaching students all the rituals o f modem medical obstetrical care.
In the early 1990s the two private hospitals in New Orleans where I practiced with
19
students had cesarean birth rates o f 50%. Students learned about post-operative care,
colon flushes for gas retention and injections o f medication for pain management. The
high incidence o f epidurals provided students’ ample opportunity to do urinary
catheterization, observe fundal pressure and forceps deliveries, and leam episiotomy care.
Interpreting electronic fetal monitoring strips was emphasized as the m ajor function o f
the labor and delivery nurse. I encouraged students to promote family-centered care,
bonding, and breastfeeding within the medical-focused practices, but I did not question
w hy medical interventions at birth had become commonplace or how alternatives to these
practices might be less oppressive to women. LDR (labor-delivery-recovery) suites and
postpartum rooming-in were models o f care held up as possibilities for improving family-
centered care and patient satisfaction. I always assigned a student to the woman w hom on
rare occasion chose “natural birth.” These women were characteristically assertive,
educated in Lamaze or Bradley childbirth, and had husband caregivers who were active
participants in the birth process. I observed obstetricians granting these women special
privileges not routinely offered the passive consumer, such as showering, liquid intake,
and ambulating. These birth situations were always special —students were fortunate to
participate in the experience.
N urse-N urse-Teacher—Writing Another Storv:
Unraveling ingrained taken-for-granted values does not happen overnight. There
w ere four simultaneous events that caused me to reflect on what I had become as teacher
and nurse. These events included coming to know the importance o f doula (woman-
caregiver), learning to be a doula, conversations and storytelling with nurses in practice,
and m y decision to return to school for a doctorate.
20
M y personal transformation from obstetrical nurse to maternity nurse was a
spiritual experience that evolved as I came to value the “doula.” During this
transformation I realized m y practice was centered on obstetrical procedures and
technology without equal consideration for the experience o f the mother and her
relationship with her baby and family. Coming to identify myself as a maternity nurse
refocused m y practice to center on the needs and desires o f women, which may include
obstetrical procedures.
In 1993, the nursing students and I were in clinical practice in a public hospital,
caring for predominately poor, urban, African American women. The childbirth rituals in
this setting were significantly more oppressive, compared to the rituals o f care I was
accustomed to in the private community hospitals. Urine drug screening was routinely
performed on all women at admission in labor. Family visitation was limited during labor
due to the labor rooms designed as “w ards,” shared by three or four women in labor. In
this setting I observed women in labor attaching to the assigned nursing student during
labor m ore so than the staff nurse, physician, medical student, or me. I came to believe
this was greatly influenced by the fact the nursing students usually cared for only one
woman in labor. The nursing student was the one person who never left the woman-
through every contraction and care procedure. I was always amazed by the way the
novice nursing students made a difference in the women’s experiences.
I connected these intuitive observations in my practice to Dr. Klaus’ work that
centered on emotional needs o f the mother. I attended a conference where he introduced
research about the doula, the woman caregiver who provides comfort and emotional
support and never leaves the woman during labor. This was the year he had co-authored
Mothering the Mother (Klaus, Kennell, & Klaus, 1993). I began questioning why my
21
values in practice and teaching seemed to focus so heavily on the obstetrical management
o f the women while the emotional, caring aspects were in the background? Both are
important, but how did one come to overshadow the other? Another colleague I teach
with, Rosa, also attended the conference and we conferred on our observations.
A month after we heard Dr. Klaus, Rosa received an advertisement from the
International Childbirth Education Association for “doula training” with Penny Simkin at
a retreat in Jacksonville, Florida. This was the year Penny co-founded Doulas o f North
America and she was conducting conferences to teach caregivers to be doulas and leam
how to become doula teachers in their community. Rosa and I made a request to the dean
to attend this event and were approved for travel. O f the approximately fifty women
there, one-third were nurses in OB practice or childbirth education. Other participants
were nurse and direct-entry midwives, women who offered professional support for
women in labor, non-nurse childbirth educators, and women concerned about birth
trends. Penny was an artist at connecting each o f us to why we were there and what
helping women give birth meant to each o f us. Although we all came from varied
backgrounds, we seemed to have arrived bonded to one cause. When Penny asked for
introductions, I identified m yself as an educator o f nurses, one who was concerned about
the role nurses play in wom en’s births. I shared that I wanted to leam more about
teaching maternity nurses to be more centered on women rather than only institutional
rituals. The women applauded. This is where I first learned the extent o f how other
women perceived nurses as one o f the major obstacles to normalcy in birth. The art o f
labor support and the emotional and comfort measures I learned at the doula workshop
made m e fUrther question why I had not learned these skills in nursing school or at
22
continuing education nursing conferences. Why were we, as faculty, not teaching this
“art” to our undergraduate students?
A fter doula training, I assisted with private labor support for a few women. One
woman was a physician who had a peer relationship with her obstetrician. Yet she still
sought assistance from a woman-caregiver to empower her to negotiate the system for the
few options that were important to her, such as sitting in the rocking chair during her
induction o f labor until she felt ready to go to bed. M y clinical teaching practice with
students also gradually changed to center on the w om an’s personal goals and
experiences. I returned to private care settings for clinical sites. W hen I made rounds on
women in labor to make assignments for students, I began spending m ore time assessing
what personal birth goals the women had, then assisting the students to focus on these.
For example, a woman who told me she wanted to avoid an epidural was later having
back labor. She voiced how she wanted to sit up completely and get out o f bed.
Fortunately, she had an order for “bathroom privileges” written when she was in early
labor. The woman agreed to a covert plan whereby every half-hour w e ceased the
continuous fetal m onitoring and the student assisted her to “ambulate” to the bathroom-
just to sit on the toilet, which was more comfortable. She met her goal to give birth
without an epidural, which I believe was greatly facilitated by her movement. Such
experiences made m e keenly aware o f wom en’s need for support to confront rituals in
medicalized birth. I continued to ponder why such an obviously beneficial intervention
required covert nursing actions? Both the staff nurse on the unit and I knew that getting
permission to ambulate her during active labor would be met by physician resistance that
might even jeopardize her bathroom privileges.
23
The same sum m er I attended the doula workshop in 1993,1 was offered an
opportunity to work in a faculty practice position when a state public hospital opened a
new obstetrics unit for low-risk women. I was relieved o f teaching responsibilities that
summer and worked as an OB educator, assisting the director o f obstetrical nursing
services prepare to open the unit in September. In the fall two faculty peers, Rosa and
Christine, agreed to share the position with me so we could maintain involvement in the
project while still teaching. For a year w e assisted the nursing director o f obstetrical
services to create an environment o f family-centered care. She set the goal o f woman-
respect as the primary initiative for the unit. We were asked to develop an inservice
program to sensitize maternity nurses to reconsider values around woman-respect and
choices in childbirth care and family-centered care. Christine, Rosa and I planned the
workshops as small group sessions with nurses in each group session representing
different areas in m aternity services.
W e wanted nurses to appreciate the whole experience o f the woman-client and
understand care perspectives unique or common to each service area. I searched
childbirth education literature to find articles and readings the nurses reviewed
beforehand to spark group discussion. I found a book o f short stories written by a nurse,
Jane Dwinell (1992) who recalled births she attended. Dwinell shared the stories,
critiquing the role o f caregivers from a feminist, woman-centered perspective.
The nurses who read the stories immediately identified with the situations. Discussions
opened about the injustices women undergo during childbirth and how nurses impact
women’s experiences. To our surprise, the nurses shared stories o f their personal birth
experiences and their nursing experiences caring for women. An older nurse recounted
how she remembered her lips were taped during her own labor because she screamed too
24
loud. Another criticized Dwinell’s metaphor describing traditional care as a “merry-go-
round” for being too mild. This nurse gave examples from her practice that demonstrated
a more descriptive metaphor would be “roller-coaster ride.” Having conversations with
the nurses helped me understand more about the forces that impact maternity nurses’
ability to care for women. Meanwhile, Christine, Rosa, and I began to work more as a
team, needing to plan these sessions together and sometimes debriefing after sessions to
discuss what went well, what did not, what we should do differently next week. We
discussed the possibility o f requiring our students to read Birth Stories for the 1994-1995
school year, since our experiences had been so powerful with the nurses.
The nurse educator in me was excited about the new possibilities I had stumbled
upon. Combining a faculty practice activity and teaching responsibilities had been a
stimulating experience. Unfortunately, during this time, academic nursing had offered me
few experiences for professional growth outside o f teaching students. The faculty practice
experience had been one o f the few instances in the nine years I had been at LSUMC
where I had the opportunity to collaborate with faculty from another school at the
medical center or nursing service staff at the state institutions outside o f student teaching.
Even membership on medical center committees was limited by nursing administration to
a few select faculty. Being excluded from academic stimulation in these ways sent a
strong message that m y voice was not valued in the university.
I married Frank in 1985, the first year I started teaching at LSUMC. During the
nine years that followed, m y husband’s mother and father died o f cancer five years apart.
Even though I was interested in returning to school, family obligations took priority.
After Frank’s mother died in 1993, m y husband and I agreed we were in a position for me
to return to school on a part-time basis. I wanted to study “nursing” which meant leaving
25
the State o f Louisiana, where the only doctoral program was located at LSUMC. I
preferred not to attend school at the institution where I was employed; I valued the
possibility o f learning new perspectives on nursing by attending another university.
However, family obligations with my parents kept me from being able to consider
m oving out-of-state for full-time study. I found three universities offering summer only
course study.
I started studies in the Ph.D. nursing program at Georgia State University,
sum m er o f 1994, which committed me to 4 summers o f study in Atlanta. My only
reluctance regarding this decision was that I would be expected to choose a nursing-
education focus for dissertation study. I was interested in nursing and women’s health
care; but nursing education was not a topic I looked forward to studying. I had lived
nursing education for so long, why would I want to study this? Because I had no option
but a sum m er program o f study and Atlanta was more convenient for my husband to visit,
I decided I had to do whatever was asked o f me to attain the privilege o f returning to
school. However, as I began the first summer o f study m y perspective on doctoral study
changed. Nursing education became a liberating experience that connected m y personal
and professional life experiences to m y doctoral studies.
A fter being sensitized by the doula conference, I found that the maternity care
issues confronting m y practice stayed with me in doctoral study. I was given the freedom
to express these in m y scholarship and study the first summer, 1994. Studying philosophy
o f science I critiqued the effects science has on human experiences such as birth. In
nursing theory I studied Benner’s (1984) work regarding nursing knowledge embedded in
clinical practice and nursing story and Benner & W rubel’s (1989) views on
phenomenology and caring. I sought and found validity for my experiences using story to
26
teach nursing care. The introduction to feminist theory in nursing and being a student in
feminist classrooms helped me come to recognize and articulate m y discontent w ith the
nursing education I had come to know and practice. This personal transformation
empowered me to start moving to another level in education. A fter the first summer o f
study I returned to LSUMC challenged to redefine m y nursing education practice as I had
my clinical nursing practice.
Transforming M aternity Care: Feminist Friendship
During summer 1994, my first summer in Georgia, Rosa called and told m e that
there had been opposition to our idea to require Birth Stories (D w inell. 1992) to
supplement the maternity nursing text for the nursing students in the fall. We had not
made this recommendation until May, failing to meet the BSN Program curriculum
com m ittee’s February deadline for requesting book changes for the fall semester. Rosa
wrote the committee a memo for a special request, since the bookstore reported no
problem getting the book. I was far enough into my doctoral study that summer to give
Rosa a few nursing references to go with our request to validate the importance o f
narrative pedagogy. The book was eventually approved.
This set the stage for a tedious process that continued as w e negotiated the school
structure to make changes. The school was divided according to “programs.” The
Baccalaureate (BSN) Program was made up o f administration and committees through
which course changes were filtered. The curriculum committee, composed o f all BSN
administrators and peers appointed by BSN administration, was responsible for reviewing
and approving curriculum issues. “Major” curriculum revisions w ere forwarded by the
curriculum committee to the BSN faculty group to approve. From our first experience o f
seeking approval for Birth Stories (Dwinell, 1992) as a text, Rosa, Christine, and I
27
became a team with a shared vision. It turned out that our experience working together in
the faculty practice project was good training for what was to come. Each one o f us
played a different but critical part in the metamorphosis o f the childbearing course from a
traditional undergraduate OB course that primarily focused on the medical model to one
that teaches the many perspectives necessary to enable the students to provide woman-
centered care.
Up to this point we lectured only in classes, taking turns based on our areas o f
interest. The first year we used Birth Stories (Dwinell, 1992) the only thing we “planned”
differently was to assign readings from the book to accompany the lectures on labor and
delivery. W e were totally unprepared for the dramatic change that happened in the
classroom. The classroom cam e alive with questioning, consideration o f many
perspectives, students’ personal birth stories, and concern for women’s experiences. No
longer needed for teaching, slides and transparencies were quietly put away. Students
learned core content regarding nursing care in labor, without exclusive lecturing on these
topics. Students passed the tests and were more aware o f how wom en’s experiences are
controlled by routines in the current medical practices.
At the end o f that academic year (M ay 1995) we faced a critical turning point.
The course syllabus, theory and clinical learning activities were designed for a
behaviorist learning and lecture format. Being inspired by our classes the past two
semesters, we wanted to encourage more class dialogue and cooperative learning. We
w anted to acknowledge multiple sources o f knowledge, including nursing stories, and
w om en’s traditions o f birth. W e wanted clinical learning to focus on the quality of
wom en/fam ilies’ experiences and on critiquing the health care system for the presence or
absence o f women-centered care. We re-read the course syllabus with the eyes o f
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feminist educators and were disturbed by the tone “our” voices portrayed. Our voice in
the syllabus was full o f negative, power-over statements that suddenly seemed
oppressive. The objectives were pertinent to clinical care, but reduced the nursing
knowledge to nursing process rhetoric that centered care primarily on assisting with
medical care rituals. Illness-oriented nursing diagnoses did not fit our view o f pregnancy
and birth as normal.
Our philosophy o f nursing and nursing education was no longer consistent with
the programmed course. As seasoned faculty, we recognized that any changes would
require institutional approval from peers and program administrators. From our
experience, we perceived the environment o f the school not to be conducive to creativity,
but rather to valuing the status quo and institutionalized icons such as the course syllabi.
The written course syllabus was equated with the course and it was through the syllabus
that courses were controlled. I had served as “chair’' o f this committee in the past and was
aware o f the attitudes and values this committee seemed to embody, regardless o f the
individual members assigned each year. We knew it would require a lot o f patience,
energy and time to articulate to faculty peers and BSN administration what we needed to
do. We were faced with two difficult choices. We could openly plan course revisions and
go through the review process where we would undergo much criticism. Or we could
choose to work covertly, keeping the external syllabus the same but changing the
classroom teaching next year to whatever we wanted —similar to what we had done the
past year. We believed the value o f the syllabus was greatly overrated; we felt most
students rarely read or used it anyway. Facing this choice represented what Hodges
(1997, p. 352), described as resolving “epistemological tension” either by “going
underground” or “going public.” In the end, because we considered the syllabus to
29
represent our voices as teachers, we were motivated to change it, and thus, we chose to
go through the public review process.
When the course ended in May, we requested that the curriculum committee give
us a month to present some “other” alternative for our course. At the time we were not
sure what the alternative would be. Because we did not want to use the same syllabus
format as all other courses in the program, our request for change was labeled a “major
revision” o f a course. During this m onth o f creating some “other” syllabus, w e consulted
with faculty, who worked as National League for Nursing site visitors for accreditation,
for their opinion o f the educational standards expected concerning a course syllabus. Dr.
William Doll, a curriculum theorist at LSU-Baton Rouge, talked w ith us about our
teaching ideas. These experts encouraged us to create a course blueprint that would
express our desire o f the heart to create a new course atmosphere, while also respecting
institutional boundaries.
After a formal presentation o f the new syllabus to the curriculum committee and
then to all BSN faculty, we received approval for a course syllabus blueprint that focused
on the use o f critical questions, rather than objectives and lecture outlines, to guide
student learning and class dialogue. The review process also approved changing teaching
strategies from lecture format to group dialogue for classes and journal writing for
clinical reflection, rather than written care plans.
What we realize now, which could not be well articulated in the beginning, was
why changing the way we taught was so important in helping students value a philosophy
o f woman-centered maternity care. W e could not enable nursing students to value
woman-centered maternity care and to critique the health care system for gender
oppression, while simultaneously teaching nursing in a paternalist manner, expecting the
30
students to learn and validate their knowledge in a patriarchal tradition. “Lecturing to” as
the only means o f sharing knowledge, over-valuing empirical data and de-valuing tactial
knowledge, the wide teacher-student power gap, always validating knowledge as one
right answer, expecting students to leam and do things alike were all antitheses to the
philosophy o f care w e held dear. H ow could we sensitize them to being woman-centered
nurses and offering choices and empowering women, if we could not demonstrate more
student-centered ways to teach, empowering students to be active learners, and offering
our students more input into their educational experiences? We came to understand that
changing the format o f a syllabus and teaching strategy from lecture to dialogue w ere
superficial changes compared to the “real” curriculum revision o f teaching students to
value woman-centered maternity nursing.
Our primary concern was how to value this view and still ensure that the students
would possess the clinical knowledge necessary for current practice. H ow could w e
combine standards o f current practices with personal consciousness and awareness o f
social, political, and pow er relations that control women’s reproductive experiences? We
were willing to take this challenge and strove to meet both objectives. W e questioned if
the values o f nurses w ould ever change in this community if we did not teach different
values? We often practiced with our past graduates who seemed to take-for-granted the
current practice rituals as part o f their job.
As the transformed course w as implemented in the fall semester o f 1995, the
classroom environment centered on dialogue, games, stories, autobiography, and creative
projects. Faculty became members o f the class each week participating in this dialogue
and learning. Because students had not been exposed to this way o f learning in their
nursing curriculum, we had to orient each class to the rationale for collaborative learning.
31
We were relieved when students passed the same multiple-choice in-class tests we had
designed for testing lecture content. However, students complained o f high test anxiety
because they had “no lecture notes” to study. W e listened to suggestions students made.
Students were pleasantly surprised at being asked to give input in decisions about course
content, grading and exams. To relieve their anxiety, we experimented with take-home,
short answer, and essay tests.
Faculty learned how to deal with passion, anger, confrontation, and spirituality in
the classroom. Unlike experienced nurses, the novice students could not initially believe
Birth Stories (Dwinell, 1992) until after they entered clinical practice. Clinical learning
was refocused to center upon the student critiquing wom en's experiences around a
philosophy o f woman-centered care. Journal writing and storytelling were used to
validate the student's connection to the clinical experiences and to evaluate their
transformation toward valuing woman-centered care.
The experimentation with new teaching/evaluation strategies evolved based on
faculty and student experiences. We made mistakes, such as developing take hom e tests
that took students far too much time to complete (and faculty far too long to grade). After
experiences with a few groups o f students resisting dialogue or a couple o f students
dominating the discussions, we changed the physical format o f the classroom to small
circles that promoted a sense o f collaborative responsibility for others’ learning. We
developed critical questions to direct the students’ thinking as they read Birth Stories
(Dwinell, 1992).
Overall, student evaluations were positive. Positive comments focused on the
caring and empowering atmosphere o f the classroom and the more personable, collegial
relationship with the faculty. Students often expressed how their perspectives about
childbirth remarkably changed after taking this course. We realized that the novelty o f
doing something different was both exciting and confusing to students. W e respected
students who honestly told us they liked “lecture” classes better. We listened to the male
voices in the early sessions o f the semester that felt alienated by studying only about
women. We heard the students who had difficulty accepting that the purpose o f nursing
education includes learning about women’s issues as well as clinical care practices. One
student accused us o f having our “personal” agenda. In a few instances, w e received
“hate letters” posing as course evaluations. The anonymous messages w ere written from
a point o f view articulating total disgust for feminist ideology and values. The messages
were full o f personal insults and threats to the school if we did not stop teaching this way.
We view these messages as signs that our teaching is being effective in sensitizing those
students to another perspective about women, although it is a view clearly rejected by
some. W e aim for multiple perspectives, taking into account the disparities in wom en’s
experiences as defined by differences in class, race, ethnicity, and sexual orientation.
We are appreciative o f the teaching peers who trusted us enough to give us the
freedom to learn how to move nursing education to a new level. In living through this
process, we experienced two juxtaposed views. Faculty were either “for us,” showing an
interest in what we were doing, seeking out recommendations for changing their courses
and offering encouragement and support, or faculty were “against us,” demonstrated by
being aloof, suspicious, questioning our motives and assuming the worst. Because graded
care plans were no longer required in the course, it was assumed we (and the students)
had minim al “work” in this course. We were accused o f “watering-down” curriculum.
Because many rituals in the school retain values and teaching methodologies we do not
use, Rosa, Christine and I have experienced living in a dominant culture o f nursing
33
education that is incompatible with our personal beliefs and worldview. Due to our
previous experiences in the culture, we recognize the values as something w e have
rejected through our risk-taking behaviors (Hodges, 1997).
We w ere not prepared for the personal toll on us. The first year, we found
ourselves being marginalized and labeled as troublemakers who tried to circumvent
institutionalized rules, including unwritten traditions. This reputation followed us to other
aspects o f our work. Creating something new in this environment was challenging. While
some faculty admired and cheered us on for being persistent with what we thought was
right, we felt the difficulties we encountered were in part designed to discourage others
from making bold changes. Having the deans o f the school support our work helped us
feel somewhat “protected,” although this perception was never discussed with them.
Our greatest validation that we had done the right thing came from our
experiences w ith students in the clinical area and in the classroom. We lived through
students’ transformations as we watched their attitudes change, read their journals full o f
insight and personal connection, and listened to autobiographical accounts o f connected
learning. I was fortunate to return to GSU for the next three summers. In the nursing
education classes with Dr. Tommie Nelms and Dr. Dee Baldwin I was given opportunity
to share my experiences and reflect on the theoretical and practical aspects o f teaching
maternity nursing in this manner. Faculty and peer interest and encouragement at GSU
sustained me and I shared perspectives from my schoolwork with Rosa and Christine
when I returned. In the summer o f 1995 I wrote a paper about our experiences that was
later published (Giarratano, 1997). I was also taking course work at LSU-Baton Rouge in
curriculum theory, where faculty such as Dr. William Doll, Dr. Denise Egea-Kuehne, and
Dr. William Pinar opened me to relate my experiences within postmodern, feminist, and
34
autobiographical theory. Rosa, Christine, and I shared our experiences with other nursing
educators through national and local poster and speaking presentations. Another source o f
support came from the white males we are married to; although I’m not sure they
completely understood what this was all about, we each found our respective husbands
supportive o f this adventure.
Our feminist friendship became, as Heilbrun (1989) described, “the enabling bond
that not only supported risk and danger but also comprehended the details o f a public life
and the complexities o f the pain found there” (p. 100). W e were able to successfully
make the changes we did in our school environment because there were three o f us
willing to take the risks and share the work. We worked hard together and supported each
other in the ups and downs. We never looked back from where we came. The challenge
and adventure o f changing faculty and students’ relationship with maternity education
were worth all we went through.
I learned from this experience how much the public sphere is defined by values o f
the patriarchy, even the public spaces women traditionally occupy, such as a m using
school. Nursing is wom en’s domain but nurse educators cannot break from traditions
founded by male power. These traditions include being expert knowers, rule seekers,
devaluing the intuitive, denying that we have an emotional and feminine side in our work,
being submissive to authority, being fearful o f breaking out o f the box, being afraid o f
what the patriarchy will think o f us and how “they” will resist us. I remember after a
nursing education presentation Rosa, Christine, and I did in New York, a young man
came up to tell m e he enjoyed the presentation. He said that he “used to know” som eone
a t _______ that taught that way ~ but she could never be tenured teaching like that.
These conversations serve as constant reminders o f the dangers o f what we are doing.
35
This reminds us that we are challenging a patriarchal educational system that requires us
to be passive and submissive in order to become a part o f the system, much like women
in health care situations who are expected to be passive consumers. But challenging the
dangers is also part o f the adventure that “fuels our fire” to change patriarchal values in
nursing education and prevent others from defining what wom en’s experiences should be,
whether it is in health care or higher education.
Knowing there are dangers in this adventure I wonder what happens to the novice
nurse we educate who take feminist values into health care institutions that may not
embrace the feminine. Are we introducing too much tension and pain in the public lives
o f these new nursing graduates who enter maternity practice with feminist values? Will
these graduates have the support systems w e had? What w ill be their personal rewards?
Finding Mother/Being Mother:
M y mother is 42 years older than I am. I was her last child. M y siblings were 18,
13, and 8 years old when I was bom. I grew up as an only child, but with older siblings
coming and going around holidays and college schedules. When I was out with my
mother as a young child I remember we would meet someone who asked her if I was her
grandbaby? She would laugh and say no, I had been their big surprise. She would always
follow this, saying something like “but we have enjoyed her so much. I don’t know why,
but it’s different when you are older -- you ju st enjoy babies more when you’re older than
when you had them young.”
A fertility specialist told me once, “You probably did not think much about
waiting to have a baby because your mother was older when she had you.” I’m not sure
his statement was altogether true, but the age o f parents and the cycle o f life cannot be
escaped. I found m yself recently at the age o f 40 trying to balance fertility treatment,
36
Ph.D. school, major changes in work, and care o f disabled, elderly parents who lived 250
miles from where I live.
For 4 years my siblings and I kept our parents at home, where they wanted to be,
while rotating weekends to check on them and the hired help in the home. I was allowed
tim e-off from this responsibility to go to school in the summer. By the fourth summer I
was in doctoral school my parents were sharing a room in a nursing home. M y father died
before I started this dissertation and my mother is still at the nursing home. At a time
when I wanted to put m yself into the last chance for having a baby, I found m yself
changing diapers on elderly parents. I do not blame them for this. Knowing m y parents
were nearing the end of their lives made m e long for new life more than ever and inspired
me to reflect on what I want in the second half o f m y life — should I live as long.
When I married I was thirty years old and I assumed someday there would be a
baby. I did not feel compelled to seek treatment until five years after marriage when I
required GYN surgery for an unrelated reason. My husband and I went through a year o f
follow-up with a fertility specialist. Each failure to conceive was more painful than I had
ever imagined. This surprised me at first because I was not aware o f how the desire to
bear a child was so intertwined into my psyche. I had never thought m yself driven to this
goal, but when it came down to achieving this, I came to know that it was a part o f me.
Somehow I was able to put my personal experiences “on the side” and go about being the
obstetrical nurse and “programmed” nurse educator I w as in the early 1990s. We took a
period o f time o ff but I knew I would reconsider treatment again. I was 36-37 years old
then.
Frank’s mother was dying from breast cancer. Six months after her death, my
father, at age 85, had a stroke and became disabled. I wondered how much more family
37
caregiving I could do when it always meant death. With the memory o f the fertility
failure fresh in my mind, part o f me wanted to go back into it again, but I needed
something solid I could fall back on if that failed. At this point m y self-esteem was so
interwoven into the outcome that I did not know what would be left after another series o f
failures. The only thing I could imagine would stabilize me was returning to school and
finding some purpose with that side o f myself. At least that was the argument I made to
my husband when I told him I was applying to school. For m e, acceptance into school
meant I could return to fertility treatment one more time. B ut after my return from the
first summer o f school, there was no fertility treatment. I was busy with m y parents,
taking my first elective course at LSU-Baton Rouge, working full time, and my husband
seemed disinterested. For the first time I had to deal with feelings that conflicted with m y
nursing practices. I began to doubt whether I could effectively practice in maternity
settings when I was consumed by my personal experience w ith childbearing. I questioned
if I would have to give up the area o f nursing I had enjoyed and in which I found
meaning? Rosa, Christine, and I were working on the new course changes to present to
the faculty and I knew w hat a fight that would be. I wondered what impact this “battle”
over the course changes would have on feelings o f powerlessness in other areas o f m y
life? With some professional help, I sorted through all this and found meaning in my
experiences. I am now able to appreciate the capability o f w om en to cope with the
complexities o f life and societal expectations. I knew others depended on me to cope with
all the issues going on and I found a way to do that. The next year I was strong enough to
risk reentering fertility treatment and also strong enough to give this up and look for other
ways to express my creativity and seek a new life.
38
In seeking fertility treatment I entered a culture o f women’s reproductive health
care where I experienced the hope and failure o f technological reproduction (Franklin,
1997). I carefully chose the reproductive procedures I underwent. M any options were
offered and available. Making the decisions helped me understand what value I put on
my family and myself. Financial restraints were a consideration —a price-tag m ade some
options too expensive to consider. This corresponded to what m y siblings and I
experienced when choosing care options for our elderly parents. Choosing less optimal
care due to the high cost o f health care in these situations helped m e understand the
vulnerability people/women o f much less privilege must experience when they seek
health care.
In my experiences, caregivers in the culture o f reproductive technology were
individuals going about their work with good intentions. However, the culture limits the
individual caregiver’s ability to care. I experienced depersonalization o f care w hen the
protocols were so standardized that m y specific needs and desires w ent unheard. I felt
this depersonalization each time a critical aspect o f my health history was overlooked. I
was put on the standard conveyor belt o f tests and procedures. Each time there w as a
review o f my case, the nurse and physician repeatedly recommended a certain test that I
felt was not appropriate for me. The caregivers obviously struggled with the ability to
individualize care and consider the context o f infertility in each person’s case. A t the
initial visit a photograph was taken, recording m y face in the chart —yet in spite o f their
efforts, m y identity remained obscured.
Despite my nursing knowledge about the problems associated with reproductive
technology, I entered the culture willingly, as do many women o f privilege with the hope
o f childbearing. As I reflected on m y experiences, I recognized an analogy between my
39
personal experience and what I believe women endure during childbearing. I understand
why women look for experts to recommend the tests, technology, procedures and
protocols through pregnancy and childbirth. The social and personal expectations for
women to successfully accomplish safe passage in this reproductive transition are
powerful. High expectations are placed on women to get this right. I have witnessed
women agreeing to almost anything if told by an expert, “This is the best thing for your
baby/* Although no one can guarantee pregnancy outcomes, the power o f the medical
expert and a patriarchal culture to offer safe passage controls women’s options. Other
possibilities for safe passage are not options when women do not know these exist or if
women are not empowered to seek alternatives.
Living through the experience allowed me to find meaning in infertility that
enabled me to return to m y maternity nursing practice and teaching with renewed hope.
Despite my lack o f personal life experience with childbirth, I have found a professional
and personal connection to women’s reproductive experiences. Because o f my own
experiences I have a greater appreciation o f how women negotiate their lives and
resources to fulfill this gender-specific expectation. Few women escape this expectation
living in a social environment that defines the meanings o f gender and reproduction for
society and specific cultures. I believe feminist theories about motherhood make
conscious the ways society influences women’s reproductive functions. Examples o f such
theories include: psychoanalytic feminism (Chodorow, 1992) which asserts that women
are possibly motivated by the desire to reproduce fond memories o f their mothers;
cultural feminism that highlights the feminine qualities associated w ith matriarchal
values; and radical feminism that recognizes oppressive socialization in a patriarchal
40
society that values women by their ability to reproduce, preferably a male child, to pass
down wealth (Donovan, 1992).
The Blended Life:
The life I expose for this autobiography is composed from the intricate cross
stitch o f threads weaving together the professional and personal, the public and private,
safety and adventure. Like many women, my life has been negotiated to meet m y
commitments while I worked for my potential (Bateson, 1990). No decision, action, or
crossroad was taken without considering the impact on others around me. I was both
forced and empowered to recreate m y world and I am poised to continue. The tensions I
experienced professionally and personally centered on the desire to create even in the
face o f adversity and obstacles. In turn, the tensions and unexpected ruptures in life may
be what provided the opening for me to imagine new possibilities. M y greatest challenge
is still seeking to create new possibilities for my family, the students I teach, the women I
care for and m yself as a woman, nurse, and nurse-teacher.
My teaching and practice o f nursing are intertwined. I teach so future maternity
nurses will have the knowledge, values, and skills needed to evaluate and question
practice and make changes. In my nursing practice I seek opportunity to engage women
to know there are many perspectives on childbirth and through knowledge they can gain
the self-confidence needed to make personal and meaningful choices. M y personal
agenda is fueled by the injustices I witness in care situations and the subtle ways health
care “experts” control wom en’s knowledge and options.
Currently, on a part-time basis I make prenatal and postnatal home visits for a
health care maintenance organization in order to maintain my nursing practice skills. I sit
face-to-face with women in their homes. I hear their concerns over how to get through
41
this life passage. For example, I have experienced a young primigravida asking m e “w hat
control do I have over m y birth options”; while a women experiencing her second
pregnancy cannot begin to talk about her next birth without recalling the losses she
experienced with the first birth experience. She wants things to be different this time.
Then some women voice no desire to be involved in decision making —they trust the
medical expert to make all the right decisions. I listen to each one. I contemplate how my
assistance can lead to their empowerment to seek personal growth in birth experiences,
while trusting their care providers.
This is a complex issue that encompasses changing women’s and health care
professionals’ knowledge and attitudes. Can the health care delivery system for normal
childbirth, characteristic o f a factory assem bly line, be re-created w ithin the dom inant
medical discourse? Can changes in the health care delivery system occur without
changing women and health care providers’ attitudes? Does one area o f concern need to
change before the others will? From my nursing practice and my conversations w ith
maternity nurses, I have come to understand the values o f nurses and the power m edical
discourse exerts over nurses’ practices. As a nurse educator my expertise lies with
educating the maternity nurse to seek ways to deliver gender-sensitive, competent care.
Education o f maternity nurses is what m y professional w ork and research focuses on at
this time. As I imagine another world where the woman writes her life as a story o f
possibilities not yet known, I am challenged by Bateson’s (1990) words, “those wom en
who succeed in adopting traditional male models leave the world very much as it is” (p.
233).
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Assumptions Related to the Phenomenon o f Concern
I shared the following assumptions in order to expose, and m ake conscious, my
prejudices that m ight impact this study o f woman-centered maternity education and
maternity nurses’ lived experiences in practice. Using Gadamer’s (1990) notion o f the
“positive concept o f prejudices” (p. 152), I recognize these assumptions are my opening
whereby I experience the world. As I conducted this research study, and interpreted
research data, I did so with the awareness o f my personal beliefs and values that
surrounds maternity nursing, nursing education, childbearing women, and the healthcare
delivery system.
My attitudes concerning this study were influenced by my experiences as a
wom an living in a patriarchal society that values men, science, and medicine over
women, nature, and nursing. My experiences working as a maternity nurse the past 22
years and as a nursing faculty member the past 20 years influenced m y values concerning
nursing care for women and nursing education. My assumptions that evolved from m y
study o f feminism and childbearing, woman-centered care, postmodernism, and
curriculum theory are as follows:
1. The maternity experience is a powerful event in the lives o f women. Whether the
experience is perceived positively or negatively, it greatly affects w om en’s psyches.
2. The maternity experience and reproductive options in W estern culture are socially
constructed around a medicalized dominant discourse that protects the interests o f the
patriarchy, i.e., men, religion, science, and the heterosexual lifestyle.
3. Each woman attaches a unique, personal meaning to childbearing. Each woman
experiences reproductive transitions within the context o f her life circumstance.
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4. Healthy women are able to give birth with minimal medical intervention, with
knowledge o f alternatives and appropriate support.
5. There are diverse ways to experience birth with or without technological and
medical interventions.
6. Novice nursing students can leam the medical model o f childbirth, while
simultaneously critiquing it.
7. Novice nursing students are capable o f evaluating women’s experiences for
indicators o f the presence, or absence, o f a woman-centered philosophy.
8. Feminist-critical pedagogy provides an opening from which nursing students can
come to know what “ought to be,” based on their raised social consciousness.
9. Students attain values in nursing school that are refined in practice, yet continue
to influence how a nurse practices.
10. Each individual nurse is responsible for the nursing care she/he renders to an
individual patient.
11. Nursing education goes beyond educating for clinical health care o f humans. The
nursing profession is obligated to educate the student to live in the world consciously
aware o f the cultural, political, and social variables that have global and individual effects
on health.
12. Nursing education should be grounded in scientific principles and imbued with
personal meanings and growth experiences.
13. A nursing faculty is obligated to teach to transform patriarchal and paternalist
. health care practices to women-centered/patient-centered caring practices.
44
14. Modem progress in science and technology has the potential to be both beneficial
and harmful to hum an life. Appropriate use o f science and technology must be considered
within the context o f the situation.
15. The culture o f modem Western health care that is centered upon medical
intervention and technology is ‘‘taken-for-granted’’ and greatly influences health care
decisions.
16. The litigious culture surrounding the delivery o f healthcare impacts professional
caregiver’s care decisions and ultimately impacts healthcare possibilities.
17. Power structures in society influence nursing education and practice.
Statement o f Purpose
The purpose o f this study was to uncover the meanings o f the clinical experiences
o f registered nurses working in maternity settings subsequent to studying maternity
nursing from a fem inist perspective in a generic baccalaureate nursing program. It was
anticipated that tensions new graduates experienced in assimilating woman-centered care
into the realities o f practice would be revealed within their lived experiences.
Selected M ethod and Justification for its Potential
A qualitative method was chosen for this study since the individual nurses were
studied situated w ithin the context o f a human experience. Phenomenology philosophy
and research methodology were used to study the lived experience o f maternity nurses.
M aternity nurses in this study shared the human experience o f entering maternity practice
after being educated about woman-centered maternity care during their undergraduate
maternity course. Heideggerian phenomenology was used to describe and interpret the
lived experiences to clarify distinctions and similarities in the nurses’ experiences
Benner, (1994).
45
Heideggerian phenomenology contends that lived experience occurs through
"Being-in-the-world," where the observer cannot be separated from the world. Recalling
and transcribing lived experience transforms experience into a "textual expression o f its
essence," (van Manen, 1990, p. 36) where the experience can be relived and reflected
upon. Reflection on lived experiences, where the taken-for-granted is brought into
awareness, takes place after the experience has happened or been lived through. Lived
experiences are described through language and can be transcribed into text. Researching
lived experience within Heideggerian philosophy is an act o f interpretation o f the
transcribed text, known as hermeneutics w here the researcher becomes engaged with the
text and comes to a shared understanding w ith the meanings o f the text. Hermeneutics
requires the interpreter to be conscious o f prejudices and reflect upon those prejudices
during the process o f interpretation (Leonard, 1994).
The goal o f hermeneutics is "discovery o f meaning that is not immediately
manifest to our intuiting, analyzing, and describing" (Cohen & Omery, 1994, p. 146). The
researcher must go beyond what is directly given in the narrative to look for the clues in
the hidden meanings in the everyday experiences. Researchers enter Heideggerian
research with a historical, temporal, and/or contextual sense o f being (Leonard, 1994).
Critical hermeneutics calls one to go beyond the most obvious interpretation and to keep
a suspicious attitude in looking for meanings (Thompson, 1990). In this study I used a
feminist-postmodern theory as a lens to interpret cultural messages embedded within
lived experiences of nurses who cared for women during the maternity experience. By
using this perspective in existential phenomenology, I was able to identity multiple sites
o f oppression associated with women as both nursing students and maternity nurses, as
well as the nurses’ perception o f current m aternity practices.
46
Phenomenologic methodology revealed the common meanings and shared
practices embedded in the lived experiences o f these nurses. These nurses’ descriptions
o f their experiences in maternity practice and their personal lives related to negotiating
their knowledge o f woman-centered maternity care into the realities o f practice were
explicated. A hermeneutic interpretation o f the nurses’ lived experiences revealed the
shared practices and common meanings in confronting potential tensions caused by
feminist ideology and practice realities. A feminist lens was used to interpret the
described experiences and bring to light embedded assumptions o f dominant discourse
and themes o f oppression nurses perceived in the delivery o f care to childbearing women.
My research with maternity nurses who were taught woman-centered ideology as
students in their basic maternity nursing course illuminated the meanings feminist
ideology had on their nursing practices as well as their personal lives. The potential
impact feminist ideology had on maternity practice situations was described through the
lived experiences o f these new graduates. Clinical stories revealed the nursing practices
that resulted from graduates who were taught to value woman-centered maternity
nursing.
There was a need to closely examine nurses’ experiences practicing in institutions
or in specific situations where a woman-centered philosophy was not embraced. This
research study illuminated nurses’ experiences and negotiation in situations where
woman-centered philosophy was not valued. Knowledge o f new graduates’ tensions and
coping strategies in these experiences can inform nursing faculty to better prepare
students to deal with practice realities that are antithetic to a model o f woman-centered
care. Factors were exposed that facilitated or limited the abilities o f the graduates to act
as role models, change agents, and to resolve conflicts with others concerning their
47
philosophy o f care. This research can enable nursing service managers, educators or
clinical preceptors to know the barriers these graduates faced in implementing woman-
centered care. Tensions that were experienced by the new graduate educated in woman-
centered care were revealed. Strategies to overcome any identified barriers to practicing
woman-centered care can be further explored. As a result o f this study nursing strategies
in education and practice to oppose barriers to woman-centered maternity care can be
proposed and researched to strive for more improved “gender-sensitive” health care
delivery.
Significance to Nursing
In 1976 (Ashley), nursing activist Willa Scott Heide declared, “sexism is
dangerous to your health” (p. v), as she proposed that feminist education was the way to
correct sexism in healthcare delivery. Heide strongly proclaimed, “feminist education
must, in m y view, becom e central to nursing education, practice and research” (p. v). At a
time when feminist theory was beginning to move into mainstream undergraduate
nursing curriculum, I had the opportunity to study the impact o f feminist education on the
practice o f entry-level nurses who are educated in the practice o f woman-centered care. It
was unknown to what extent nursing students, educated in a woman-centered care
philosophy, accepted and sustained feminist values.
This study o f nurses’ experiences had the potential to reveal information specific
to feminist education and nursing practice. When feminist values are embraced, what are
the tensions new graduates face as they attempt to practice woman-centered care? How
do new graduates, who disregard woman-centered values or perceived themselves unable
to practice woman-centered care, deal with their com plicity in sustaining a medical
48
model o f childbirth? How do nurses resolve internal struggles as they tried to negotiate
two paradigms o f care?
I believed researching ways new graduates, who were educated in wom an-
centered care and assimilated feminist values into their nursing practices, was central to
advancing gender-sensitive healthcare systems. B y listening to graduate nurses’ stories,
insight could be gained into their levels o f healthcare knowledge and their sensitivities in
analyzing health care through a feminist critical lens that deconstructs dominant
discourses and practices. The study was to describe how m aternity nurses perceived they
fit into the patriarchal practice o f women’s healthcare. Understanding how resistance to
the patriarchy manifested itself in nursing practice could contribute to knowledge needed
to transform health care delivery. Likewise, forces that sustained patriarchal traditions
and represented power over women and nursing care practices needed exposure.
My prim ary impetus for teaching woman-centered care, and investigating the
im pact feminist ideology had on maternity nurses’ practices, was to change healthcare
delivery and im prove maternity care. I anticipated this study would provide a glim pse
into the ways maternity nurses, who were educated in woman-centered care, perceived
their impact on the healthcare delivery system and women’s experiences. I anticipated the
nurses’ views o f what constituted empowering or oppressive birth experiences for women
could be described and the meanings shared through their clinical stories. I anticipated
the potential effects woman-centered philosophy had on caring practices and the
interpersonal relationships and conversations between nurses and women-clients could be
described from the nurses’ perspectives. Tensions and conflicts experienced with
physicians and expressed by nurses related to delivery o f woman-centered care could also
be exposed. It was anticipated that maternity nurses’ attitudes o f midwife birth attendants
49
would be described. The influence o f learning woman-centered care in undergraduate
nursing school and the consideration o f advanced practice education to become a nurse
m idwife could also be explored.
Nurses' personal lives can be affected by sensitizing them, as students, to gender
oppression in society, and w om en’s oppression in healthcare. It was anticipated that this
study would contribute to understanding the impact this level o f self-awareness would
have on nurses’ personal life experiences including their own healthcare and childbirth
experiences, and/or the experiences o f their significant others.
Learning m ore about the nature o f the nursing care environment in maternity
settings through the eyes o f the new nurse was anticipated to provide insight into the
social transformations necessary to create and sustain women-centered models o f care. It
was anticipated that this study would contribute knowledge to the ways feminist
education in m aternity nursing impacted nurses’ personal lives and professional practices,
and would advance the goal o f achieving woman-centered health care for women.
Summary
In this chapter, I described the purpose o f the study and the phenomenon o f
concern surrounding implementation o f woman-centered maternity nursing education,
and the need to investigate how this educational strategy impacted the practice o f
m aternity nursing. I centered the background o f the study on the patriarchal model o f
childbearing, characterized by routine medical intervention and technology, that restricts
w om en’s choices and increases risk for healthy women. I proposed reform o f maternity
nursing through a woman-centered philosophy o f care. I validated feminist pedagogy,
using educational and nursing literature, as an effective strategy in nursing education to
raise social consciousness regarding wom en’s healthcare experiences, and advance
50
reforms for woman-centered care. I exposed m y background as a teacher, nurse, and
woman, and my assumptions related to the research, as the opening through which I
conducted this study. I justified phenomenology research methodology as an effective
way to study the lived experiences o f maternity nurses in practice situations. Finally, I
discussed the study’s significance to nursing, as a means o f transforming maternity
nursing education and healthcare delivery for women..
CHAPTER II
CONTEXT OF THE STUDY
In this chapter I explicate the theoretical and research contexts surrounding
feminism, woman-centered childbirth, maternity nursing practice, and education. The
theoretical context situates the origins o f woman-centered ideology within a constellation
o f feminist and postmodern theories. I begin by critiquing feminist and postmodern
theories to consider their adequacy for explaining childbearing and maternity nursing as
gendered experiences, defined by dominant discourse and m odem models o f health care
delivery. I overview Michel Foucault’s postmodern theory o f pow er and review feminist
critiques on the usefulness o f Foucault’s theory in feminism. I present the feminist and
postmodern notion o f “woman as other,” to explain how wom en experience multiple sites
o f oppression due to the cultural meaning o f gender. A body o f critical literature
reflecting diverse feminist and postmodern perspectives on childbearing is overviewed to
demonstrate the ways theorists use these perspectives to critically analyze childbearing
and expose the oppressive nature o f taken-for-granted health care practices.
I overview historical origins o f woman-centered health care. I describe the
philosophical and operational tenets associated with woman-centered health care and
childbirth, including the co-option o f woman-centered care by the health care system. I
present cultural analyses o f Western birth practices revealing m odem discourses and
power relationships among childbearing women, the health care culture, and the
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52
caregivers that are considered problematic for woman-centered childbirth. I contrast
discourses surrounding traditional care practices in technocratic birth with principles
espoused within a discourse o f woman-centered or holistic care. I describe social
movements and com peting discourses pressing for childbirth options within a m odel o f
woman-centered care. These include efforts through the World Health Organization
(WHO), the Coalition for Improving Maternity Services (CIMS), the Doula movement,
and the renaissance o f midwifery.
I explore the connection o f feminist and postmodern theories with nursing
practice through a review o f the nursing literature. The uneasy relationship between
feminism, postmodern thinking and nursing is revealed. I explore the impact o f feminist-
postmodern and emancipatory theories on nursing practice, research, and education to
find support for using these theories to develop woman-centered care as nursing praxis.
This discussion is followed with an overview o f obstetrical or m aternity nursing as a
professional specialty. I take a stark look at the influence the patriarchal obstetrical
medical specialty had on the evolution o f maternity nursing. I overview current trends in
maternity practices, social activism, and research for their potential to improve
humanistic and women-centered childbirth care practices. Lastly, in this section, I look at
a collection o f m aternity nursing texts and locate dominant discourses that represent a
body o f knowledge valued in the discipline. I critique discourses embedded in the texts
looking for ways the discourse interfaces with woman-centered maternity nursing.
I propose a woman-centered maternity nursing education to affect changes in
practice. I use the curriculum theory o f Patti Lather, M axine Greene, and William Pinar
to support a transforming, feminist-postmodern curriculum necessary for teaching
woman-centered care to nursing students. I propose this curriculum theory is foundational
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to understanding the pedagogical context o f nursing students’ education that m ay create
nursing praxis to alter wom en’s experiences and options in maternity care. Finally, I
review nursing research that describes the effects o f feminist pedagogy and the
emancipatory classroom on nursing students’ learning and personal experiences in
professional education.
The Theoretical Context
Introduction: Feminism and Postmodernism
Critical analysis o f twentieth century childbearing discourses and health care
practices is explicated in the literature through a “constellation” (Bernstein, 1992, p. 8) o f
contemporary feminist and postmodern theories. Bernstein’s metaphor o f constellation
demonstrates juxtaposed theories, such as feminism and postmodernism, that contribute
to the understanding o f human concerns while resisting reduction to any essential center
or stable norm. W ithout complete convergence, the pairing o f postmodern and fem inist
theories opens possibilities o f conversations about childbearing and maternity nursing
outside dominate medical discourses.
The cluster o f feminist and postmodern theories locate childbearing and m aternity
nursing within the theoretical shifts in historical, social, economic, and cultural life
characterized by the postmodern condition. Postmodern perspectives aim to expose the
context o f social and cultural conditions of life and question the assumptions o f truth in
m odem discourses. W hile postmodernism attempts to explain the conditions o f life,
feminist practice and theory aim to transform the postmodern condition, improving
w om en’s lives (Wicke & Ferguson, 1994).
The constellation o f modem/postmodem theories that explain gender and
childbearing in Western culture resist complete integration and reconciliation o f all
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“difference, otherness, opposition, and contradiction” o f theoretical strands (Bernstein,
1992, p. 8). The contrasting forces offered through feminist and postmodern theories
offer multiple interpretations o f gender, childbearing, and nursing. Feminism and
postmodern critique decenters childbirth discourses that evolved from modem,
patriarchal values grounded in “the Enlightenment.” In doing so, the constellation o f
feminism and postmodernism avoids a grand either/or dichotomy. The either/or debate in
maternity nursing practice centers on the assumption that rational, universal norms exist
to critique childbirth experiences for a generic woman. Maternity practices are designed
around the assumption that universal norms are used to ensure a controlled, safe birth or
these universal norms o f care are not used, thus putting the birth event out o f control and
unsafe. Rather than entering the debate over universal norms, the pairing o f feminism and
postmodernism offers the possibility o f “new styles and genres o f critique that avoid the
extremes and twin dangers o f this either/or” (Bernstein, 1992, p. 8). The instabilities and
ruptures revealed with a pairing o f feminism and postmodern critiques open the
possibility for a both/and perspective where multiple discourses, meanings o f childbirth,
and care alternatives are considered and valued.
Theoretical discourses surrounding feminism and postmodernism are considered
“porous,” “capacious,” “discourses on the move,” (Wicke & Ferguson, 1994, p. 2)
crossing borders and blurring boundaries. There is no stable definition o f feminism or
postmodernism (Bernstein, 1992; Doll, 1993; Jardine, 1985; Simpson, 1994; Weedon,
1997). Being mindful o f this, I overview the spectrum o f possibilities, limitations, and
meanings surrounding feminist and postmodern perspectives in the following section. I
begin by reviewing the possibilities and problematics concerning contemporary
feminisms, postmodernism, and Foucault’s theory o f power analysis in the postmodern.
55
This is foundational to return to what Wicke & Ferguson (1994) call the “awkward
pairing” (p. 1) o f feminism with postmodernism.
Contemporary Feminisms
M odem twentieth century feminism represents the search for progressive
identities for ‘w om an’ through social and political movements. Feminist movements
originate out o f w om en’s struggles living in a culture that separates economic, social, or
political spheres b y gender. The cultural separations result in women being assigned a
less valued position than it does men. Feminism describes the intellectual and political
efforts on behalf o f women to resist the undesirable conditions contributing to w om en’s
devalued social place. A belief central to feminism is that women who are conscious o f
their situation can collectively change their place in culture and thus change their
gendered experiences as women (Humm, 1992; Simpson, 1994).
The notion o f a first wave feminist movement followed by a second wave
fem inist m ovem ent is an effort to describe the progression o f gender empancipation in
the twentieth century. Both first and second wave feminist movements are historically
situated and represent episodes o f social reform. However, the theorizing and activism
that characterizes the feminist movements are not necessarily linear or distinct from one
another. For example, women’s struggle with the state for equal rights under the law is a
site o f resistance that remains constant throughout the twentieth century. The fight for
suffrage that characterizes first wave feminism during the 1920s is followed in second
w ave feminism by the struggle for the constitutional right to privacy to protect and gain
reproductive rights (Wattleton, 1996).
Evidence o f first wave feminism in Western culture emerged as women in the
United States and Britain sought equalities through the state during the early twentieth
56
century. First wave feminists theorize that with economic and political rights women can
transform themselves and the world. Legal advances and public emancipation in this era
created a political identity for women through the struggle for the vote, contraception,
welfare rights, and legislation regarding women in the workplace.
Second wave feminism acknowledges female differences from m en as an
offspring to oppose a patriarchal world. Feminist standpoints and identities based on
differences from men emerge, such as reproductive rights. M odem feminists during this
era began using male-generated theories such as M arxism and critical social theory as
tools to articulate their experiences o f gender inequality. Dominance theory serves as a
point o f departure for the development o f feminist theories and critiques o f gender
oppression. Ideology, consciousness-raising, and praxis represent three such Marxist
tenets common to modem feminisms (Donovan, 1992; W eedon, 1997).
Ideology refers to processes by w hich meaning is produced, challenged,
reproduced, and transformed. Ideology forms the basis for discourse and action in
society. The ideology, or meanings o f gender, sexuality, and patriarchal structures serve
as the analysis o f power relations in society that expose oppressions women may
experience. The act o f consciousness-raising enhances w om en’s self-awareness o f sites
o f oppression and activates women who, if they feel oppressed, must then take political
action to change their situation. Consciousness-raising connects personal experiences to
feminist activism revealing that “the personal is political.” This extended Marxist
ideology that consciousness o f oppression was primary for the oppressed to be freed to
take action and to shed “false consciousness” whereby oppression remains invisible.
Consciousness-raising occurs through a collective discussion o f personal experiences o f
women where conflicts and contradictions are exposed.
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The ability to go through the processes o f consciousness and seeking to change
one's circumstance is considered a revolutionary process, known as praxis. Emancipatory
social changes occur as a result o f praxis where theory is put into action (Lather, 1991).
As Donovan (1992) states, praxis is considered a positive activity that entails a "free,
creative engagement in the world by the individual, who is changed by the experience
and who thereby changes the world" (p. 70). The notion o f praxis is consistent with the
idea o f reflective consciousness identified by phenomenologists who distinguish humans
as having ability to step back from the world, reflect upon it and freely choose to create
an environment according to their interests.
Praxis is experienced through the alternative developments in women's culture
(Donovan, 1992). Alternatives in women's culture are often expressed as a nonviolent
revolutionary means o f resistance, such as women's publications and establishment o f
women's health centers (Ruzek, 1978). The gay/lesbian community represents a culture
o f resistance that fights stereotypical hegemony regarding sexual orientation and the
patriarchal family. The home birth movement is recognized as an alternative and resistant
action to medicalization o f childbirth in patriarchal institutions (Rothman, 1982).
Using the tenets o f dominance theory in feminism is not without problems. The
universalizing nature o f Marxism and critical social theory put limitations on the ability
o f m odem feminisms to consider multiple interpretations o f ‘woman,’ and explain
notions o f oppression and emancipation within diverse situations and cultures. For
instance, women o f color and lower socioeconomic status point to the elitist nature o f
consciousness-raising that often approached issues only from a white, upper middle class
perspective (Collins, 1990; Weedon, 1997). At the end o f the twentieth century there is
the hope o f continual movement to go beyond the universalizing definitions o f women’s
oppression, liberation, and life experiences (Hekman, 1996; Marshall, 1994). The hope
offered feminism through theoretical constellations o f postmodernism moves feminist
theorizing to consider difference and otherness beyond the project o f emancipation. Hope
offered through postm odern theorizing gives rise to a “third wave” o f feminism situated
in understanding and transforming the postmodern condition.
Historical overview o f first and second wave feminist theory development in the
twentieth century show s degrees o f strengths and limitations in attaining ideals o f gender
emancipation (Donovan, 1992; Kourany, Streba, & Tong, 1992). The W omen’s
Liberation M ovement (WLM) o f the 1960s evolved from divergent feminist theories and
theoretical strands such as liberal, cultural, Marxist/socialist, radical, psychoanalytic. In
the practice o f feminism these strands often blend as feminists locate oppressions within
varied situations where no one theoretical strand stands alone to improve women’s status.
To clarify the points o f divergence, I overview and critique the tenets and praxis
commonly associated with each theoretical strand. In doing so I expose possibilities and
limitations o f m odem feminisms to articulate, critique, or change w om en’s experiences
around reproduction and motherhood.
Liberal feminism.
Liberal feminists theorize from the basis that each person is bom with inherent,
natural rights (Donovan, 1992; Kourany, Streba, & Tong, 1992). W oman is presented as
a rational independent being, worthy o f human dignity and all rights o f citizenship
afforded equally with men under the law. Liberal feminism strives for political and legal
rights for equal treatm ent o f women and men in the public sphere. Liberal feminists
confront resistance to attain economic, legal, and educational rights that are foundational
to women’s liberation. Yet, liberal feminism is criticized for devaluing feminine
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personality traits and discounting biological difference in the cause for equality.
Liberalist arguments for equality are insufficient to consider the biological issues o f
pregnancy and maternity leave, where men and women are not equal.
The gravest shortcoming o f liberal feminism is it’s failure to account for the
private sphere. Liberation o f women is equated to women recognizing their desire and
right to work in the public sphere (Friedan, 1963). Liberal feminism fails to take into
account how women's roles as domestic caretakers in the family structure often
complicate women's participation in employment and educational opportunities even
after the right is obtained. Issues such as decisions regarding fam ily life, pregnancy, and
rights o f women surrounding reproduction are left to individual choice and self-
determination. Women's legal "choices" are often still controlled by patriarchal structures
(Weedon, 1997). Liberal feminism also lacks adequacy to explain other differences that
affect enjoyment o f rights, such as race, sexual preference, and socioeconomic factors
(Donovan, 1992). Feminists such as Gordon (1991) analyze how “equal opportunity
feminism’’ (p. 7) failed to transform society as women entered the workplace as male
clones and gained status by m erely reproducing the capitalist w orld previously defined by
men.
Cultural Feminism.
Cultural feminism espouses the struggle for rights as m erely a means to achieve
larger changes in social order. Cultural feminists seek to restore feminine characteristics
for the good o f mainstream society. Such a "matriarchal vision" for "feminization o f
culture" is achieved by illuminating feminine characteristics o f harmony, intuitive
perception, nurturing and moral sensitivities as seen necessary for the survival o f the
world (Donovan, 1992, p. 32, 35). While cultural feminists celebrate the feminine they
60
also confront difficulty in explaining what constitutes the difference in male and female
identity or in the feminine or masculine. Believing only the female gender is biologically
capable o f "feminine” characteristics is veering toward biological determinism, which
limits the notion o f a human free will (Bleier, 1991; Harding, 1986). Cultural feminism
tends to romanticize issues o f “home,” “childbearing” and traditional domestic roles.
Cultural feminists often ignore the fact that patriarchal structures contribute to myths
about the glory o f these feminized roles. Motherhood is an example o f a glamorized
feminine role used to benefit the patriarchal family. W omen are m ade to feel they must
achieve the standard o f the ideal perfect mother regardless o f the social circumstances
that impact the achievement o f this goal.
Socialist Feminism.
Socialist feminists espouse the revolutionary theory consistent with its Marxist
roots. The project o f empancipation centers on critiquing the labor o f women in
traditionally unpaid domestic work. Domestic work, such as housework, meal
preparation, childbearing, childrearing, and breastfeeding is presented as central to the
success o f capitalism, yet women are not adequately compensated for the labor and thus
are exploited by capitalism (Donovan, 1992). However, since M arxist theory centers on
work outside the home in form o f wage labor, socialist feminism is inadequate to fully
explain the oppression o f wom en’s role in reproductive and domestic work, which
remains largely invisible in society (Simpson, 1994). Because w om en’s oppression in
reproductive work is noted in countries that are not capitalist or post-capitalist
(communist), there exists incongruities in explaining capitalism as the root all gender
oppression. Socialist feminists account for sexual and reproductive control o f women by
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pointing to the institution o f patriarchal marriage, which they equate with lifetime slavery'
(Donovan, 1992).
Psychoanalytic Feminism.
Psychoanalytic feminists theorize about psychosexual construction o f gender in
the modem family structure and the nature o f women's oppression that originates within
the family (Kourany, Sterba, & Tong, 1992). Freudian theory describes a pre-Oedipal
stage o f maternal-infant attachment followed by the child's resolution o f the Oedipus
complex and adherence to society’s sexual norms. Sociologist Nancy Chodorow (1992)
uses Freudian theory to study why women want to mother, even when they have the
option not to do so. Chodorow theorizes that incomplete separation o f m other and
daughter leaves the daughter with desire for relatedness —to care for others before
meeting her own needs and interests. Identity with the mother may produce a desire for
daughters to reproduce fond memories o f their mothers and childhood. Critics o f
Chodorow think her hypothesis that feminine personality causes family structure should
be reframed to articulate how family structure causes feminine personality. Limitations to
Chodorow's analysis is the fact that she used the white, heterosexual, middle-class,
capitalist family as the prototype for psychosexual development (Spelman, 1992).
Radical Feminism.
Radical feminists theorize that gender oppression is much more invasive in
culture than can be corrected by legal, political, and economic structures alone,
recognizing the patriarchy as the root o f all women's oppression. Radical feminists claim
gender oppression is embedded in cultural and social institutions o f the family, church
and the academy, and must be eradicated at all levels. Radical feminists aim to overcome
whatever subordinates women to men. Female biology is considered a site o f oppression
62
unless the woman determines control. Radical feminists often choose w om en’s health
issues as a site for political and social activism to resist the control o f women based on
their biological differences. Radical feminists established women’s health care clinics
and fought for pro-choice rights and childbirth reforms in the early 1970’s (Deveaux,
1996; Donovan, 1992; Ruzek, 1978).
According to radical feminists, societal values about femininity and
heterosexuality are used to subordinate women to men. Evidence o f this oppression is
manifest in capitalism, law, education, pornography, prostitution, sexual harassment,
rape, battering, foot binding, clitoridectomy, witch-burning, and gynecology (Daly,
1978). Radical feminists suggested that ways to escape male oppression included
reinterpreting feminism and separating it from heterosexualism and men. This separatist
idea may be accomplished through celibacy, autoeroticism, and lesbianism (Hawthorne,
1991). Women choosing heterosexual relationships are empowered through radical
feminism to act on their desires and claim control over the role expectations o f “w ife”
and “mother.” Women o f color and lesbians have found space to theorize about gender,
family and childbearing issues unique to them. This offers alternatives to white,
heterosexual radical theory and sensitizes health care providers to diverse perspectives
concerning childbirth (Bunch, 1991; Collins, 1990).
Postmodernism
Postmodernism is a movement o f the late twentieth century considered too
difficult to pin down or describe in an overarching definition. Postmodernism serves as
an “umbrella” for an array o f discourses that theorize about the crisis o f modernity.
Postmodernism is a broad, inclusive concept that represents the larger cultural,
theoretical, and aesthetic conditions associated with post-industrialism and post-
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colonialism. “Postmodernism” refers both to a historical period and to shifts in theoretical
perspectives that provoked questioning the certainty o f modernity to solve problems or
create a better world (Doll, 1993).
The postmodern critique o f modernity centers on questioning epistemological
features o f the political movement known as “the Enlightenment.” This W estern
tradition assumes disembodied reason produces an accurate, objective, and neutral
account o f the world. The rational subject is thought to exist outside o f time, space, and
pow er relations. Logical reason and science assumes a universality o f truths and human
nature, where differences are inconsequential. Duality, inequality and dom ination are
established in the name o f progress. Common dualities o f domination present themselves
in the modem era as man/woman, science/nature, us/them (Bernstein, 1992; Rorty, 1989).
Rights o f the individual precede the rights o f community, nature and the environment.
Devalued Others were created as the Enlightenment denied the relationship between
pow er and knowledge (Harstock, 1996).
Postmodern theorizing rejects all “grand theories” or metanarratives presented as
one logocentric account o f history, philosophy, or power. No theory is privileged or truth
absolute. All knowledge is bound by culture and history. Pluralism o f traditions, values,
and ideologies are recognized. Specifically, post-structuralists within the postmodern
movement displaced the idea o f stable language, texts, and subjectivity (Derrida,
1982/199la). To the postmodernist, all meanings in texts are never final, but constantly
being deferred, w hat Derrida (1982/199lb) called "differance." The deconstruction o f
text demonstrates inconsistencies and contradictions in language and in the m eaning o f
events, revealing experiences are full o f multiple meanings (Derrida, 1988). Due to
instablity in language and meanings, postmodernists believe the personal self or subject is
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always in the making. Different fields o f inquiry embrace the postmodernist movement
fostering multidisciplinary approaches for knowledge development based on diversity,
instability, and non-linearity.
Critics o f postmodern perspectives fear this thinking strips society o f foundational
beliefs and values necessary for achieving human solidarity to solve human problems.
Habermas (1987) espouses the Enlightenment as an unfinished product and warns that
postmodernism fosters nihilism, relativism and irresponsibility. Using postmodern
thinking to deconstruct the modem world is feared to merely be introverted
contemplation that lacks action to solve problems. On the other hand, Derrida
(1991/1992a) believes it is irresponsible not to deconstruct events and language to expose
contradictions and reveal how language and discourse create reality. Derrida (1992b)
presents postmodern deconstruction as a means o f action -“the taking o f a position, in
work itself, toward the politico-institutional structures that constitute and regulate our
practice, our competences, and our performances" (pp. 22-23). Derrida believes
postmodern deconstuction is not destroying the foundations o f society but, “constructing
something else, something other..." (Montefiore, 1992, pp. 6-7).
Power Relations in the Postmodern: Michel Foucault
Pow er relations within a postmodem/post-structuralist view are often articulated
through the work o f Michel Foucault (1975/1977; 1976/1990; 1977/1980) who
revolutionized ways o f analyzing and understanding power. Without rejecting domination
ideology, Foucault looks further to explain w hy traditional beliefs about power are
insufficient to explain how power permeates every fiber o f society. Foucault believes
power was present in every relationship (not ju st in binary relationships, such as
ruled/ruler) and is exercised from infinite directions. Foucault’s work locates pow er at the
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micro-level, where the w orkings o f power manifest itself in everyday events and
relationships. He questions how power relations constitute subjectivity and control how
we function within relationships. Although Foucault’s analyses reveals the working o f
power, he is criticized for raising questions but offering no corrective suggestions.
Foucault (1977/1980) believes power circulates through the production,
accumulation, and circulation o f discourse that functions as knowledge and truth as
described in the following passage:
Each society has its regime o f truth, its ‘general politics’ o f truth:
that is, the types o f discourse which it accepts and makes
function as true; the mechanism and instances which enable one
to distinguish true and false statements, the means by which each
is sanctioned; the techniques and procedures accorded value in
the acquisition o f truth; the status o f those who are charged with
saying what counts as true. (p. 131)
The “regime o f truth” influenced by common meanings and values o f society form the
dominant discourses accepted as appropriate ways o f thinking and knowing. Yet
discursive or competing discourses arise to challenge or contradict dominant discourse.
Which discourse gains dominance over the other is a result o f social, political and
historical influences. The production and diffusion o f knowledge/truth that constitutes
discourse is delegated to institutions such as the church, university, military, media, and
publishers.
Foucault’s analysis of power centering on techno-scientific discourse provides
insight into understanding the pre-eminent authority and status granted scientific health
care within Western culture. O f special interest to Foucault (1977/1980) is how
knowledge/truth/power within the techno-scientific discourse contrails the body in
modem society. He used the term “biopower” to identify the efforts o f science within the
biological and social sciences to study and regulate humans. Foucault interprets society’s
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preoccupation with scientific knowledge as a desire to manipulate human bodies for
society’s purposes, notably economic and procreative purposes (Dreyfus & Rabinow,
1982).
At the micro-level Foucault identifies how power relationships maintain the status
quo using what he called disciplinary techniques. According to Foucault (1975/1977)
disciplinary pow er acts as the training to maintain the body as an obedient object. As he
explains,
What was then being form ed was a policy o f coercions that act upon the
body, a calculated manipulation o f its elements, its gestures, its behaviour.
The hum an was entering a machinery o f power that explores it, breaks it
down and rearranges it. A ‘political anatomy,’ which w as also a
‘mechanics o f power,’ was being bom; it defined how one may have a
hold over others’ bodies, not only so that they may do w hat one wishes,
but so that they may operate as one wishes, with the techniques, the speed
and the efficiency that one determines. Thus discipline produces subjected
and practised Isic) bodies, ‘docile bodies.’ (p. 138)
The end-point to disciplinary pow er is to produce the docile body that is m olded by
standard rules and is passive and self-disciplining.
Three types o f discipline Foucault (1975/1977) identifies in modem systems that
result in “docile bodies" are surveillance, normalizing judgm ents and examination.
Surveillance is accomplished quite literally by observation. Foucault uses a m etaphor o f
Benthan’s Panopticon in prison structure to describe how society is likewise structured to
control others through the pow er o f observation. M odem society forms m odels o f
observation through a “network o f gazes" (Foucault, 1975/1977, p. 171) configured
around an apparatus o f observation (watch towers, technological lens, video).
Architectural designs serve as observational apparatus to control human in hospitals,
factories, schools, working class housing, and asylums. These m odem institutions
develop as systems o f organized surveillance and require specialized personnel whose
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primary purpose is to provide intense, continuous supervision. Normalizing judgement
evolves to represent the standards o f behavior and rules for punishment based on the
behaviors observed. Foucault (1975/1977) describes this evolution o f systems o f
surveillance to m onitor trivial behavior:
The workshop, the school, the army were subject to a whole micro-penalty
o f time (lateness, absences, interruptions o f tasks), o f activity (inattention,
negligence, lack o f zeal), o f behaviour (impoliteness, disobedience), o f
speech (idle chatter, insolence), o f the body ( ‘incorrect’ attitudes, irregular
gestures, lack o f cleanliness), o f sexuality (impurity, indecency), (p. 178)
A s individuals conform to the normalized behavior, the “deviant” individual becomes
visible and labeled as requiring special attention by society.
Foucault recognizes that surveillance and normalizing judgm ent also evolve
around a plethora o f minute disciplinary mechanisms, such as distribution o f space and
time. Spatial distribution o f bodies requires that each person’s body be given enough
individualized space so the body as object can be known, supervised and judged.
Foucault (1975/1977) describes the time-table’s disciplinary technique as “three great
methods - establish rhythms, impose particular occupations, regulate the cycles o f

»
repetition” (p. 149). The marching regimes o f the army, precise nursing routines and
standard procedures in hospitals, classroom cycles, and time clocks are reminders o f the
micro-disciplinary function o f tim e. Each moment o f time is also valued for “an ideal
point at which one maintains maxim um speed and maximum efficiency” (Foucault
1975/1977, p. 154).
Foucault makes reference to examination as a disciplinary technique that acts to
observe others through compiled data, such as medical charts, school records, and
statistical data. Examination evolves out o f society’s concern about the public health and
welfare o f the population. Foucault (1977/1980) describes this system o f observation
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and notation as record-keeping activities that seek to “ fix the knowledge o f different
cases, to follow their particular evolution, and also to globalise the data which bear on
the long-term life o f a whole population, and finally through substituting better-adapted
medical and pharmaceutical cures for the somewhat indiscriminate curative regimes
which formed the essential part o f traditional nursing'’ (p. 180). Examination results in
modem society controlling individuals’ behaviors by enabling experts to own
knowledge and information to monitor others’ behaviors, especially in regards to health
care norms.
The Awkward Pairing: Feminism and Postmodernism
The “awkward pairing” o f feminism and postmodernism alludes to the skepticism
o f feminists toward the philosophical possibilities o f linking postmodern theory with
feminism. Second wave feminism that espouses Marxism and m odem assumptions o f
universality conflict with postmodernism tenets. Wicke and Fergurson (1994) contend
feminists cannot escape postmodernism as a “way we live now, and it needs to be taken
account of, put into practice, and even contested within feminist discourses as a w ay o f
coming to terms with our lived situations” (p. 1). Yet, Wicke and Fergurson caution
against embracing postmodernism unquestioningly, but with eyes open to determine
“how feminism will transform postmodernism, as well as how postmodernism alters
feminism” (p. 2). Wicke and Fergurson say the ultimate task for a feminist-
postmodemism is to remain “self-aware and self-critical— to be theory” (p. 9).
Feminists differ in their perspectives o f how postmodernism and feminism can
complement each other or appear as a constellation o f theory to benefit the cause o f
gender emancipation. I present the limitations and possibilities o f pairing feminism with
postmodernism, the postmodern explanations o f power, and w om en’s gender identity as
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the Other to provide a framework that I believe offers hope to explain and transform the
postmodern condition that impacts current childbearing practices. I believe these theories
act to expose the multiple sources o f oppression for nurses and childbearing women that
originate from power relations, language, discourse, and patriarchal structures designed
by men.
Possibilities o f the Feminist-Postmodern Constellation
The feminists who embrace postmodern thinking voice discontent w ith the
usefulness o f Marxism to guide feminist praxis in the future. Postmodern fem inism
rejects a unitary theory about women. Analyses by critical and feminist scholars indicates
universality o f gender oppression as a common limitation that evolves from M arxism and
second wave feminism (Agger, 1993; Hekman, 1996; Marshall, 1994; Nicholson, 1994;
Weedon, 1997). Radical feminists emerging from third wave feminism who engage in
consciousness-raising realized that interpretations o f experience require gender analysis
to go beyond the metanarrative o f class analysis in Marxist theory (Braidotti, 1991). Just
as the Frankfurt thinkers used Marxist theory to 'move beyond Marx,' many think
feminist theory looks to postmodernism to move beyond critical theory. M arshall (1994)
identifies Marxism as representing another m odem theory that fails to adequately address
difference or diversity among women. Defining women and oppression in universal terms
fails to take into account the locality o f oppression and the uniqueness o f w om en’s
individual situations o f oppression (Hekman, 1996).
The experiences o f oppression defined by second wave feminist thought often
excludes and divides many women whose experiences and values differ from the white,
well-educated, upper-middle class heterosexual feminist. Postmodern feminists, are
poised to be aware o f difference in their theorizing and avoid the urge to colonize "other"
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women with white, Western heterosexual feminism (Weedon, 1997). The postmodern
acceptance o f a plurality o f ideas and theories recognized differences among wom en
more than traditional feminist theory.
Agger (1992), Fahy (1997), Lather (1991), and Marshall (1994) argue for
postmodernism as a critical theory that can revitalize emancipatory theory. A gger (1993)
argues for the need for versions o f postmoderism and feminism as adjectives to qualify
critical theory to counter dominance and broader dimensions o f alienation experienced in
the late twentieth century. Marshall (1994) argues for a critical moderism, "which is post
positivist, critical o f the hegemony o f Western 'reason', listens to 'local stories', rethinks
the notion o f a coherent pre-existing 'subject' and rejects the universalizing im pulse o f
'grand narratives' " (p. 159). Lather and Fahy argue that postmodernism gives the critical
edge required for emancipatory research and keeps the researcher from becom ing an
elite, detached observer.
Feminists find post-modernism provides useful ground for a critique o f science,
truth, power, subjectivity, knowledge, and otherness outside a theory o f dominance
(Simpson, 1994; Weedon, 1997). In particular post-structuralist theorizing o f Foucault
and D errida strengthened feminist awareness o f how subjectivity (self-development) is
often determined through language and meanings centered upon hegemonic discourse.
Post-structuralist theorizing explains how women’s lives are defined in patriarchal
structures in society through dom inant discourses and are thus "structural..they exist in
the institutions and social practices o f our society and cannot be explained by the
intentions, good or bad, o f individual women or m en” (Weedon, 1997, p. 3).
Foucault’s (1975/1977) analysis o f power is used for feminist analysis o f
hegemonic discourses revealing the localized forms o f gender pow er relations that define
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women in society. Postmodern feminists theorize that the patriarchy established truths
about women through fixed discourses which the woman (subject) is forced to
incorporate. Postmodern feminists believe subjectivity is not static, but historically
situated and ever-changing. Likewise, discourses on gender and femininity are never
considered "fixed" once and for all —there is no absolute truth or one interpretation o f
experience. Feminist solidarity is not expressed as a universalizing experience, but rather
as a redefinition o f w om an’s subjectivity as the “Other,” crossed over by variables o f
class, race, and sexual orientation (Braidotti, 1991). Believing the subject is never
considered a final product, postmodern thinkers believe that subjectivity can change
through consciousness-raising and that dominant discourse can be challenged and
resisted. Feminist post-structuralists use analysis o f discourse to expose power relations
that serve the interests o f patriarchy, and to plan resistance to that discourse. Thus, within
postmodern feminism the individual remains a site o f discursive struggle for identity,
leaving hope that the subject can choose to accept or resist living out a dominant
discourse. This offers hope that individual women may resist dominant discourses that
position nurses and childbearing woman to passively accept routine medical
interventions. Through consciousness-raising and awareness o f the power o f dominant
discourse, women and nurses may seek to find their own subjectivity.
Critics o f a Feminist-Postmodern Constellation
Feminists who are wary o f postmodern thinking fear postmodernism would
reduce the entire emancipatory project a mere metanarrative to be deconsstructed. The
m odem discourses o f progress and emancipation are seen as essential avenues for
articulation o f the female experience. Hartsock (1996), a feminist critic o f
postmodernism, is not willing to concede the intentions o f reason to postmodern thinking
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Hartsock acknowledges the lack o f awareness o f plurality and difference that
characterized early feminist theory development, yet she opposes replacing the
Enlightenment tradition with postmodernism. Hartsock contends postmodernism
represents situated knowledge o f intellectuals, such as Rorty (1989) and Foucault
(1975/1977), who call for conversation and analysis without sufficient action or search
for knowledge to change structures. As an alternative to postmodernism, Hartsock (1996)
invokes a need for feminists to shift their theoretical terrain to “epistemologies o f marked
subjectivities” (p. 47). This calls for the experiences o f marginalization and subordination
to be articulated and viewed as a way to develop knowledge and provide a basis for
understanding difference and forming alliances, without the aid o f postmodernism.
The notion o f personal empowerment is challenged by the postmodernist belief
that there is no stable self (Flax, 1990; Weedon, 1997). Believing the subject is an
historical and social phenomenon formed by unconscious and conscious effects o f
discourse, means there is no essential female or feminine nature innate to women. This
undermined the unity o f women as a group with common interests. The postmodern
notion o f plurality is believed to threaten identity politics. Generalizing theories o f
otherness may overlook the power relations inherent in social problems such as racism.
At a time when oppressed groups are finally finding voice, naming themselves, and
theorizing, many feminists are suspicious that the Western white male academy, from
which postmodernism originated, is questioning the possibility o f a defined self.
Furthermore, postmodern writers have offered little scholarship specific to gender
relations in Western culture (Flax, 1990).
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Feminist Interpretations o f Foucault's Postmodern Power
Feminists have mixed opinions about how Foucault’s analysis (1975/1977;
1976/1990; 1977/1980) o f power is useful to gender emancipation. Allen (1996) believes
Foucault warrants critique around the question of, “What do we, as feminists, need a
theory o f power to do?” (p. 266). Feminists find his analysis o f disciplinary pow er useful
to articulate how wom en’s bodies are dominated by normalization o f body image and
sexuality (Allen, 1996; Bordo, 1997; Sawicki, 1991). This illuminates how women
participate in their own domination. Yet, Deveaux (1996) warns this thinking sets up a
notion o f a static, docile body that has no agency for self-determination or free response
to cultural forces. Deveaux believes the capacity for emancipation and the category o f
woman should not be displaced in the use o f Foucault.
Allen (1996) believes Foucault’s theory o f power enables feminists to view power
on many levels. On the micro-level Foucault gives a constructive framework on w hich to
study abuses o f power that occur at the capillary o f society, such as the classroom or
workplace. Domination that occurs within local power relations, as seen in sexual
harrassment, is easily illuminated. Yet, Allen is not without critique o f Foucault. A t the
macrolevel o f power analysis, Allen finds Foucault incomplete to build a feminist theory
o f power. Although Foucault exposes how power circulates through cultural discourses,
institutions, and social practices, Allen contends that his explanations o f domination are
inadequate for feminist analysis and praxis. Foucault’s explanation o f domination as a
“congealed” network o f power, where there is no free circulation, is insufficient to
describe wom en’s situations. Allen believes women are more likely caught in a
“constricted” network o f power, where options vary for exercising power and are
different or unequal for women. It is not that a woman can never exercise power in
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situations o f dominance, such as sexual harassment, but that her degree o f resistance is
determined by multiple factors such as money, information, language, and cultural
support. Allen (1996) also believes Foucault fails to address the deep structures o f
domination such as gendered division o f labor and the cultural meanings o f femininity,
masculinity, and sexuality that vary along lines o f race, ethnicity, and class. Allen calls
for feminists to recognize the contributions o f Foucault’s account o f power, but to
continue the search for constructing a feminist theory o f power to understand w om en’s
domination.
Woman as Other
According to postmodern feminists, the discourse o f “woman as Other” penetrates
society through philosophy developed for and by m en (Weedon, 1997). Philosophy
becomes “conceptual weapons o f phallologocentric thought” (Braidotti, 1991, p. 212).
Beginning with Descartes’ mind-body split, philosophy set a mode o f thought w here the
human being became two “different kinds o f entity” —a mind or soul that constitutes
“certainty and value,” and a body to be “subordinated and ruled” (Cole, 1993, p. 56). A
power dialectic is produced in which the rational mind must triumph over the body. This
dualism is played out in Western culture, where the m ind is privileged over the body.
The Cartesian rationalism acts as a masculine ego in culture, setting up a
hierarchical model for m ale dominance and women’s subordination and position as “the
other” (Braidotti, 1991; Cole, 1993). M en represent the rational agent who makes order,
measures, and controls history and other subjects. Legitimization o f the masculine se lf as
“the One” rests on the exclusion o f the feminine. Affirming masculine primacy requires
domination o f woman’s bodies and exclusion o f the feminine as rational. As Braidotti
(1991) describes,
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Patriarchy is the practice, phallologocentrism the theory; both coincide,
however, in producing an economy, material as well as libidinal, where
the law is upheld by a phallic symbol that operates by constructing
differences and organizing them hierarchically, (p. 213)
W omen are stigmatized as the disciplined, docile body that participates in the
rationale schemes o f m ale social order. Organizing the sexes within a dialectic o f
one/other sets up a dualistic power relation where women came to signify the natural, the
physical and the bodily —to be tamed and domesticated by the rational man. In this
hierarchical difference women are stigmatized as the outsider as history establishes
masculine primacy. Women are linked with nature and considered less integrated into
culture than men. As “the other,” women are enslaved in a master/slave dialectic, as
Cixous and Clement (1986) describe:
What is the “Other”? If it is truly the “other,” there is nothing else to say;
it cannot be theorized. The “other” escapes me. It is elsewhere, outside:
absolutely other. It doesn’t settle down. But in History, o f course, what is
called “other” is an alterity that does settle down, that falls into the
dialectical circle. It is the other in a hierarchically organized relationship
in which the same is what rules, names, defines, and assigns ‘its’
other., .reproducing to perfection the mechanism o f the death struggle: the
reduction o f a ‘person’ to a ‘nobody’ to the position o f ‘other’., (p. 71)
The ideology o f the “rational man and the physical woman, intellectual
masculinity and corporeal femininity” (Cole, 1993, p. 68) is transformed to social reality
when the world economy values women for their sexuality and reproductive ability and
excludes them from other possibilities. W omen internalize this otherness to mean
inferiority or exclusion o f abilities and capacities that ultimately limited life options
(Donovan, 1992). This otherness became manifest in conscious and unconscious
dimensions o f the female self.
Internalized otherness created by this dualism becomes a site o f resistance for
feminists. However, a dialectical schema was created when early feminists viewed their
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difference from men as a state o f inequality. There were attempts at eliminating an
ideology o f difference in the hope that equality with men could be achieved. The
argument to abolish difference was made by radical feminists such as Firestone (1970)
who argued for the ending o f biological reproduction, while other feminists attempted to
transcend difference through liberal feminism (Friedan, 1963) or embrace women’s
difference in cultural feminism (Rich, 1986). These forms o f resistance can be understood
as a rejection o f the system o f domination and hierarchy based on difference.
Likewise, postmodern radical feminism focuses on sexual difference since the
domination o f a woman’s body remains a primary site o f oppression. Postmodern
feminism critiques and rejects the male claim to rationality, while at the same time
seeking to free women from male-oriented views o f philosophy and intelligence.
Difference is reclaimed from the ideology o f subordination. Postmodern feminists Cole
(1993) and Braidotti (1991) recognize radical feminist reflection as a w ay to step outside
the flawed (man-made) model o f viewing otherness or difference within a hierarchy o f
domination and subordination. Cole and Braidotti theorize that feminist reflection affirms
difference as a positive value with a plurality o f meanings. While avoiding separatism,
Braidotti reveals the need to redefine the woman as a subject o f knowledge where the
notions o f intelligence and theory differ from male prescriptions. Braidotti (1991)
believes theoretical reasoning for women can be understood as a positive form of
difference. As she explained,
W omen’s thinking is always oriented toward creation, in several ways at

once: whether it looks to the past, to recover cultural traditions and ways
o f knowing by women that have not been preserved by mainstream
culture, or whether it aims at illuminating a present that women ofren
experience as conflictual and contradictory, in feminist thought critique
and invention progress together, (pp. 216-217)
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The notion o f an embodied self is another view that seeks to m ove otherness
beyond a hierarchical value (Braidotti, 1991; Cole, 1993). The ideology o f an embodied
self combined the m ind and body as equally valued constituents o f self-awareness.
Braidotti (1991) theorizes that neither biological or social conditioning alone were
sufficient to explain the difference surrounding women. As Braidotti (1991) states, “The
body is seen as an inter-face, a threshold, a field o f intersection o f m aterial and symbolic
forces; it is a surface where multiple codes o f power and knowledge are inscribed.. .The
body is not an essence, and therefore not an anatomical destiny; it is o n e 's primary
location in the world, o n e’s prim ary situation in reality” (p. 219). The embodied self is
seen as a source o f knowing where women can come to understand their own sense o f
sexuality and unique physical experiences outside a constructed male m odel. The
embodied self replaces condemnation o f the socio-biological construction o f woman as
different, meaning inferior. Affirmation o f difference as a positive value eliminates the
need to minimize difference.
Feminist/Postmodem Critique as Resistance to Childbirth Practices
A significant body o f w om en’s studies literature includes feminist and/or
postmodern critiques o f childbearing in Western culture. M any o f the critiques are
academic in nature, representing the disciplinary focus o f the author, such as sociology,
psychology, anthropology, and nursing (Dwinell, 1992; M artin, 1992; Oakley, 1980;
Rothman, 1982,1989; Sandelowski, 1981; Ussher, 1989). Other works are directed to
women consumers and less academically focused, but equally potent in exposing the
power o f dominant practices to define childbirth experiences (Arms, 1994; Cohen, 1991;
Kitzinger, 1994). The author’s autobiography is sometimes intertwined within feminist
theorizing. Using autobiography as feminist theorizing includes negotiating, naming and
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understanding the author’s life histories surrounding childbirth, thus illustrating how the
personal and private spheres as women became interconnected to the public and political
world (Cohen & Estner, 1983; Davis-Floyd, 1998; Kahn, 1995; M ichie & Cahn, 1997;
Rich, 1986; Rothman, 1982).
The body o f knowledge derived by postmodern feminists’ cultural construction o f
childbearing epitomized Braidotti’s (1991) notion o f feminist reasoning. In the cultural
construction o f childbearing by feminists the past is often revisited to “recover cultural
traditions and ways o f knowing by women” (p. 217) not preserved by mainstream culture
(Dwinell, 1992; Rich, 1986). In others, feminist reflection and scholarship illuminate the
present childbirth culture women experience as being “conflictual and contradictory”
(Braidotti, 1991, p. 217). The overview that follows represents the diversity in w om en’s
thinking to recreate the gendered experience o f childbirth as “critique and invention
progress together” (p. 217). Feminist reflection destroys any claim to a logocentric
universal discourse for childbearing and motherhood.
Threads o f radical and postmodern feminism expose the effects o f modernity on
the childbirth process. Rothman (1982; 1989) closely examines the dominant patriarchal
beliefs about the prim acy o f science and technology that created an efficiency, industrial
like model o f childbirth. Rothman (1986) explores how reproductive technology and
prenatal diagnostic testing change the meaning o f childbirth and the human relationship
o f childbearing and parenting. Rothm an (1982,1989) clearly makes a call for midwifery
as feminist praxis. Likewise, sociologist Oakley (1980) explores w om en’s transitions to
motherhood in m odem society in an attempt to expose the relationship between w om en’s
oppression in society and the medical control o f the childbirth experience. As a nurse
feminist, Sandelowski (1981; 1984) further exposes the medical model for its control
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over women, including the social forces that impact nursing’s role in the delivery o f care
to women.
Many analyses demonstrate Foucault’s (1975/1977) notions o f power and
knowledge as a function o f discourse that inscribes and determines what childbirth
represents to women and how the experience is defined in culture (Ginsburg & Tsing,
1990; Treichler, 1990). Studying and critiquing discourses is proposed for women to
demonstrate an active and self-conscious role in contesting or confirming gender
identities as inscribed through dominant discourse. The language and discourses o f the
dominant medical culture are challenged in feminist critiques using Foucault’s theory o f
power, demonstrating how m odem language concerning birth creates an oppressive
reality for women.
Anthropologist Emily M artin’s (1992) analysis o f reproduction in W estern culture
reveals cultural meaning assigned to the language used in medical textbooks and in the
medical graphics o f women’s bodies. Martin finds women’s normal bodies to be
portrayed as pathological and the medical metaphors o f normal labor to reflect
mechanical work in which medical interventions aim to improve productivity. Likewise,
sociologist Robbie Kahn (1995) provides a poststructuralist critique o f childbearing,
relating the discourses o f birth to actual practices. Kahn critiques texts such as the
Hebrew Bible, Christian Gospels, and William’s Obstetrics, demonstrating them as
“disfigurements,” doing violence to the integrity o f the maternal body and nature. Kahn
calls for a social reconstruction o f the birth experience through a new language o f birth.
Deconstruction o f popular childbirth discourses in medical and consumer texts
has also been undertaken. Critical psychologist, Ussher (1989, 1992) challenges the
psychological stereotype o f postnatal depression believed to originate from “raging
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hormones.” She reframes postnatal depression as a period o f normal grief due to multiple
cultural variables that oppress women and impose the fantasy o f the “ideal mother.”
Likewise, Miche & Cahn (1997) deconstruct common discourses in popular prenatal and
infertility advice books. They demonstrate how the rhetoric o f consumer “choice” can be
used to blame women for things they have no control over, while “deflecting the blame
from social conditions” (p. 72). In a similar work, Diane E yer (1992) challenges the
medical, nursing, and social science discourses surrounding maternal infant bonding,
what she calls “a scientific fiction.” She raises critical issues about the social influences
o f science when applied to wom en’s issues. Eyer is critical o f the bonding ideology-that
belittled the complexity o f parenting to a few observable behaviors used by health care
professionals to categorize wom en’s experiences.
Feminist critiques o f childbirth are also influenced b y Foucault’s notion o f
biopower. The disciplinary power o f surveillance, normalizing judgment, and
examination are theorized by feminists to explain the pow er held over women’s bodies to
conform to societal expectations surrounding reproduction. This theorizing illuminates
the politics o f reproductive technology (Petchesky, 1996; Sawicki, 1991; Spallone, 1989).
Visualization and surveillance technology that transfbrmes the public image o f the
embryo and fetus to a person is believed to contribute to changes in social practices
(Adams, 1994; Balsamo, 1997; Bordo, 1993; Duden, 1993; Stabile, 1994; Wertz &
Fletcher, 1993). The medical gaze makes the fetus a public im age and renders the mother
an object through which to see. Discourses by Duden (1993), Petchesky (1996), and
Stabile (1994) explain how the public image o f the fetus, as displayed in Life magazine
and the film, Silent Scream, is often a disembodied one, w ith no direct connection to the
mother. Yet the power o f this visualization encroaches deeply into women’s lives. Such
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power is used for political means to control wom en’s access to abortion and to pressure
women to undergo whatever prenatal tests or care regimes are necessary to ensure a
perfect baby for society. “Normalizing judgem ents” dictate women’s actions during
pregnancy. Through examination women are categorized and controlled as medical data
is recorded during pregnancy and labor. The wom an’s personhood and ability to choose a
reproductive subjectivity are lost, as are her choices for care.
Pam C arter (1995) extends the ideology o f biopower and surveillance to an
analysis o f theoretical aspects o f breastfeeding. In her study o f infant feeding choices in
Great Britain, Carter concludes that the surveillance associated with breastfeeding in
Western culture m ay actually make bottle feeding an infant a more positive experience
for women w ho seek freedom from medical and social controls. While the “good mother”
is expected to breastfeed, society still holds m uch control over where and when
breastfeeding occurs in both private and public settings. Contrary to m any feminist
stances on breastfeeding, Carter believes breastfeeding does not always represent a viable
option for w om en because o f these societal controls, and she urges more research on
social issues related to infant feeding choices.
Feminists undertaking a postmodern critique o f the impact o f technology and
science on hum an reproduction often use the metaphor o f the cyborg —the human body
as both nature and machine. The reality o f human existence that represents the cyborg is
analyzed around reproductive technologies, such as in-vitro fertilization, that create
pregnancy through technology. The problematic issues that arise around the delicate
balance that keeps birth a “human” and natural state while using and depending on forms
o f technology are explored in postmodern analyses (Balsamo, 1997; Davis-Floyd &
Dumit, 1998).
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Summary
In this section I reviewed the theoretical context o f feminism and postmodernism
and critical issues related to the pairing o f the two ideologies. I illuminated the
possibilities offered through the pairing o f feminism and postmodernism to provide a
both/and perspective that encourages multiple interpretations o f the childbearing
experience -- beyond only the dominate medical discourse. I overviewed postmodern
pow er relations as theorized by Michel Foucault (1975/1977; 1976/1990; 1977/1980) and
summarized the work o f feminist writers who used Foucault’s theory o f biopower and
surveillance to explain power held over wom en’s bodies during pregnancy and childbirth.
This b rief overview o f wom en’s studies literature was also an example o f feminist and
postmodern resistance to dominant discourses surrounding women and childbirth. I
overviewed the feminist-postmodern ideology o f “woman as other” in Western culture as
an explanation o f the gender inequality that acts to marginalize women. This ideology o f
“woman as other” is helpful to understand why women’s biological ability to reproduce
made them different from men —but also set up a notion o f different as inferior. Overall,
the theoretical perspectives presented in the previous section demonstrated the usefulness
o f feminist-postmodern thinking to open multiple discourses around the issues o f women
and childbearing in Western culture.
In the section that follows I present historical perspectives that sparked the
w om en’s health movement and the notion o f woman-centered care during the second
wave feminist movement. W omen’s control by and resistant to dominant medical
discourses is made evident in reviewing the struggle for woman-centered approaches to
health care and childbirth. The philosophy and operationalization o f woman-centered
care is articulated from feminist literature that describes how women experienced
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liberation from dominant medical discourses. Cultural and social analyses o f past and
current childbirth practices is presented to show how sociocultural variables continue to
impact w om en’s choices in childbirth. Current movements that continue to support
woman-centered ideology in childbirth are presented.
The Feminist Health Movement: The Call for Woman-Centered Care
The notion o f “woman-centeredness” evolves from second wave (1960s-1970s)
feminist theory which acknowledges woman’s difference as an issue to be theorized and
a source o f cultural values to be embraced (Humra, 1992). Woman-centeredness
represents the ongoing goal o f feminism to understand the effects o f living the category
o f ‘woman.’ The feminist struggle to situate the body and health care as a site for
woman-centeredness is a paradox in the fight for equality with men. At a time when
women want to be acknowledged as more than bodies —doers rather than breeders —
liberation o f women requires acknowledging the woman’s body as different but not
inferior to the male body and without the need to be controlled by men. Reproductive
rights that centered on the woman’s legal right to her body became the starting point for
w om an’s liberation in radical campaigns o f thel960s. Feminists challenged dominant
discourses about the body, medical practices, and gender socialization around sexuality,
childbirth and motherhood that benefited the patriarchy (Daly, 1978; Oakley, 1980; Rich,
1986; Sandelowski, 1984).
The W om en’s Health Movement (WHM) seeks to reclaim the w om an’s body
from modem culture and patriarchal control. The WHM is a social movement that began
in the late twentieth century and uses conscious, organized, political efforts to transform
health care to benefit women (Geary, 1995; Olesen & Lewin, 1985; Rosser, 1988; Ruzek,
1978). Women active in the WHM recognize the need for fundamental changes in health
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care delivery that addresses women's identified needs and make health care accessible to
all women outside a paternalist framework.
A key issue o f the WHM is the right o f the woman to exercise autonomy (self-
govemance) and free herself to choose and make decisions about her own health care.
Autonomy is defined by bioethic feminist Susan Sherwin (1998) as “acknowledging and
protecting competent patients’ authority to accept or refuse whatever specific treatments
the health care providers they consult find it appropriate to offer them (an event known as
informed choice)” (p. 21). Based on a relational view, Sherwin (1998) believes autonomy
is exercised both “within relationships and social structures” (p. 36) that, in turn, either
foster or inhibit the individual’s potential for making independent judgments. The
principle o f autonomy is seen as an essential feature for feminist strategy to improve
health services for women. Social, political, and economic threats to women’s autonomy
in health care are identified and resisted. The struggle for autonomy means a resistance to
paternalism —the practice o f physicians making decisions on the behalf o f their patients,
without their understanding or consent, believing the superior knowledge o f the physician
justified the practice. The patriarchal privilege and social power granted to the medical
profession, and the political and economic restrictions that impact reproductive health
care, abortion and contraceptive availability are all targeted as threats to autonomy
(Sherwin, 1992).
The search for autonomy in women’s health care means a resistance to
medicalization o f w om en’s bodies. Medicalization results from shared cultural practices
that support the legitimacy o f using medical concepts and discourses to describe and
“treat” life phenomena. Medicalization functions as a powerful mechanism of social
control, which results in “the unintentional or intentional expansion o f the domain o f
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medical jurisdiction” (Morgan, 1998, p. 85). Successful medicalization is dependent upon
medical knowledge being granted the status o f authoritative knowledge (Davis-Floyd &
Sargent, 1997; Foucault, 1977/1980; Jordan, 1993). Constituting medical knowledge as
“authoritative” over other sources o f knowledge evolved as an ongoing social process
that establishes and describes power relationships in the culture o f health care delivery.
Granting the medical community authoritative knowledge in w om en’s health care
dismisses and devalues other ways o f knowing and medical intervention is accepted as
the correct way to approach w om en’s health care.
The political drama o f the WHM centers around contesting authoritative medical
discourses that devalue, trivialize, intimidate and silence wom en’s voices, health
concerns and health knowledge. The WHM rejects two powerful paradigms associated
with medicalization. Feminist caregivers reject the biomedical model o f the hum an body
that conceptualized health as a biological state o f the individual living organism. The
biomedical model viewes disease as universal across all human species and trivialized
factors such as culture, race, class, gender, historical location, and sexual identity except
for their value in predictive statistics or epidemology. Feminists believe the context o f
lives is equally important to understanding and responding to w om en’s health care needs.
The biomedical model disregards the important social factors that contributed to
w om en’s health status (Morgan, 1998).
Likewise feminists w ho resist medicalization also resist the medical paradigm that
there is an “essential female” pathology. The WHM rejects the medical belief that
wom en’s normal body functions and life transitions, such as menstruation, birth, and
menopause are diseases or risky events to be treated with medicine or surgery (Martin,
1992; Miles, 1991). The WHM sparks feminist revolt as women question the traditional
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professional authority o f the male expert to exert control over women’s bodies and health
care and look for alternatives o f care not found in traditional settings.
Initially the early movement centered on reproductive health concerns and
childbirth experiences. More recently a form o f feminist resistance to medicalization
included demands for medical research specific to the effect diseases have on women,
such as breast cancer and heart disease (Morgan, 1998). Women demanded access to
early testing and treatments less invasive and sensitive to women. Subsequently the
WHM was acknowledged with bringing women’s comprehensive health concerns to the
forefront, setting the stage for wom en’s health policy on a national level. The long-term
effect o f the WHM culminated in the establishment o f a National Institutes o f Health
(NIH) Office o f Research on W omen’s Health (ORWH) in 1990 and development o f a
NTH research agenda that centers on health risks and disease prevention and management
unique to women. However, research continues to require feminist critique o f scientific
methodology applied to study w om en’s health (National Institutes o f Health, 1992;
Woods, 1994).
The WHM started within 1970s grassroots consciousness-raising groups
occurring simultaneously on the East and West Coasts o f the United States (Ruzek,
1978). The consciousness-raising groups eventually led to larger public forums. In
Boston a group o f wom en reacted to their experiences with condescending, paternalistic
physicians. The Boston group researched and wrote papers on women’s anatomy and
physiology and common health care concerns regarding venereal disease, birth control,
abortion, childbirth, and the inadequacy o f the health care system in attending to women.
The women began teaching health courses in women’s home, churches, and nursery
schools. The papers were eventually bound and evolved into the popular manual, Our
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Bodies. Our Selves (The Boston Women’s Health Book Collective, 1973), which had a
circulation o f 225,000 copies. In March, 1971, the first W omen’s Health Conference was
held in New York and health issues usually reserved for male professionals were
discussed among women. Feminist issues evolved from topics such as contraceptive
devices and drugs, sterilization, research experimentation, surgical abuse through overuse
o f hysterectomies and radical mastectomies, and inhumane childbirth practices.
Meanwhile, self-help gynecology and feminist health care clinics were also
transforming health and body issues into a social movement (Chalker & Downer, 1992).
In Los Angeles on April 7,1971, Carol Downer, a member o f a woman’s group that met
to discuss health and abortion issues at the Everywoman’s Bookstore, performed a
vaginal self-examination with a speculum. Carol Downer invited the other women
present to observe her cervix. Demonstrating the easy accessibility o f wom en’s anatomy
led Downer and a small group o f activists to organize a “Self-Help Clinic.” As Downer
(Chalker & Downer, 1992) explained, ‘T o us, ‘self-help’ meant taking control o f our
bodies and our health care” (p. 114). Self care groups were organized to reeducate
women about their bodies from a feminist perspective, demystify the pelvic exam, and
teach women self-care o f common health problems (Federation o f Feminist Women’s
Health Centers, 1981). Women were empowered by self-help groups and women-
generated health literature to become knowledgeable health care subjects. Self-help
advocates bypassed medical experts to publicized techniques for artificial insemination,
first trimester abortions, and menstrual extractions and demonstrated the collective power
o f women to challenge authoritative medical knowledge (Chalker & Downer, 1992;
Morgan, 1998).
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After the Roe vs. W ade decision in 1973, the self-help groups focused their
efforts on buying clinics to establish feminist health care centers. Professional caregivers
with feminist values worked with lay wom en to expand services, including medical
abortion. W omen’s Feminist Health Centers opened in Los Angeles, Santa Ana, San
Francisco, Chico, San Diego, California, Portland, Oregon, Tallahassee, Florida, Atlanta,
Georgia, and Washington State (Ruzek, 1978). A Federation o f Feminist W omen’s
Health Centers (FWHC) was established. W omen working in these clinics focused their
attention on maintaining woman-centered health care education and practices and worked
to keep abortion options legal and safe. Currently six FWHC are still in operation but no
formal FWHC network exists. Several other non-profit clinics exist that are outgrowths
o f the “FWHC” model. (J. Schrammeck, personal communication, M arch 28,1999).
The goals o f the FW HC to protect w om en’s reproductive rights are consistent
with the goals o f the Planned Parenthood Federation (formerly the Birth Control
Federation o f America), founded in the 1920s by nurse activist Margaret Sanger. Sanger
fought legal barriers, opened clinics, educated the public, provided contraceptives to
wom en and men and fought for medical research to expand birth control methods. Sanger
was a crusader for women’s rights. She believed women could not achieve the right to
control their lives until they had the pow er to control their fertility. Planned Parenthood
was founded on woman-centered values and provided primary health care for the purpose
o f assisting women to control their fertility through contraceptive or abortion services
(Planned Parenthood Federation o f America, 1991).
Although this organization was founded on feminist values, the organization took
directions under male leadership in the 1940s that concerned Sanger. Sanger disapproved
with the name change to “Planned Parenthood,” believing this put emphasis on
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“parenthood” rather than on the key issues regarding the sexual and reproductive life o f
women. Sanger feared this minimized the social and political significance o f her mission.
Faye Wattleton, nurse midwife and president o f Planned Parenthood (1978-1992) worked
to return the organization to its roots. Under W attleton’s leadership, Planned Parenthood
took a leadership role to fight for the constitutional right to privacy for wom en to retain
and achieve rights to control their fertility, including legal and safe abortion (Wattleton,
1996).
The WHM and Federation o f Feminist W omen’s Health Centers contributed to
the movement for woman-centered childbirth. Western birth was medicalized as birth
moved from the home to the modem hospital in the early twentieth century (Leavit, 1986;
W ertz & Wertz, 1989). The goals o f the WHM to demedicalize birth supported earlier
“natural birth” movements that began in response to W estern trends. Natural birth
activists such as obstetricians Read (1944), Lamaze (19S8), and Bradley (1974), and
consumer Marjorie Karmel (1959) supported childbirth methods to change the disturbing
trends that included excessive obstetrical intervention, such as forceps, episiotomies,
over-medication, and a lack o f emotional support for women. Prepared childbirth
techniques were proposed to help women regain control o f their bodies and the birth
experience in hospital settings. However, with limited midwives, the need for the medical
birth attendant, and increasing availability o f obstetrical technology, the efforts to resist
m edicalization o f childbirth continued to be hampered (Ruzek, 1978).
The International Childbirth Education Association (ICEA) continued the natural
birth movement and the WHM’s momentum in exposing the oppressive childbirth culture
in m odem health care. Feminist perspectives and controversies related to childbirth were
discussed at ICEA’s first conference, held in 1973 by self-help founder, Lolly Hirsch, and
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psychologist Dorothy Tennov. The preceding year ICEA’s co-president Doris Haire
published The Cultural Warping o f Childbirth (1972). Haire’s scholarly writing detailed
Western society’s routine practices that were performed for the convenience o f the
caregivers with no regard to how the practices altered the woman’s experience. Haire
used research findings comparing the United States’ higher infant mortality rates to those
in other developed countries, indicating that medical intervention did not equate to
decreasing infant mortality. The shift to childbirth education as a norm in all hospitals
and gradual changing o f hospital routines at birth to include a family-centered philosophy
are credited to the political, social women’s movement spearheaded by dissatisfied
consumers (Sandelowski, 1984; Ruzek, 1978).
Cassidy-Brinn, Homstein, and Downer (1984) from the Federation o f Feminist
Health Centers co-authored Woman-centered Pregnancy and Birth as an attempt to
redefine the childbirth process from a feminist perspective that educated and empowered
women and partners to have the knowledge to freely choose among the alternative modes
o f childbirth. However, as more technology was introduced, natural birth alternatives
available to women were restricted or marginalized as “unsafe.” The routine use o f
continuous fetal monitoring, for example, limited women’s ability to choose comfort
measures dependent on mobility. Women’s bodies during childbirth were disciplined to
facilitate use o f technology for continual assessment that in turn acted to legitimize the
authoritative knowledge o f the medical expert and maintain medical control over the birth
event (Amey, 1982; Davis-Floyd & Sargent, 1997; McKay, 1991). Women and partners
seeking birth alternatives outside the medical model were taught to use assertive
communication approaches and written birth plans to negotiate with medical experts to
achieve personal goals (McKay, 1986). The International Childbirth Education
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Association (ICE A) continued to respond to this environment by developing documents,
such as The Pregnant Patient’s Bill o f Rights and T he Pregnant Patient’s Responsibilities
(Haire, 1975; ICEA, 1975).
Philosophy o f Woman-Centered Care
The Women’s Health Movement and the w ork o f activist childbirth organizations
and individuals results in the articulation o f a woman-centered philosophy for women’s
reproductive health care and childbirth. A woman-centered, feminist philosophy evolves
primarily from women’s demand for knowledge, control o f their bodies, and their right to
health care experiences that centered on their needs and desires. Primary to woman-
centered care is the value o f women’s rights to choose and make their own care decisions
and to consider their best interests. W omen-centered philosophy frees women to retain
their life values, maintain autonomy and still receive quality care by humane practitioners
(Holmes, 1980; Ruzek, 1978).
Woman-centered philosophy changes the balance o f responsibility and authority
believed appropriate between the caregiver and the wom an (Holmes, 1980; Morgan,
1998; Ruzek, 1978; Sherwin, 1992; 1998). Physician privilege, power and domination
through paternalism is exposed and corrected. In a woman-centered philosophy, the
relationship between medical authority and the w om an is based on mutual participation.
Health care providers who value woman-centered principles describe their role as advisor
or consultant. The dominant role and power o f the expert is challenged by a change in the
social distribution o f medical knowledge. Health care professionals or lay providers do
not assume to own exclusive knowledge to persuade women to make decisions. Women-
centered providers believe their role is to share knowledge and perspectives with women,
while expecting women to educate themselves through many mediums and come to their
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own decisions. W omen’s education is believed to occur through the health care system,
or through consciousness-raising groups, listening to other women, family or friends, or
self-study.
Inherent to woman-centered care is the belief that women's knowledge comes
through connecting mind and body, which enables women to understand and know their
bodies (Holmes, 1980). This, in turn, gives women special expertise to share with the
health profession. Woman-centered philosophy o f care insisted, that with adequate
information, women are the most competent ones to choose health care or birth options.
Only the woman can make informed decisions that consider her best interests within the
context o f her life situation. The health o f the woman depends upon awareness o f the
psychological, emotional, and physical wholeness o f the woman/mother-to-be and the
baby.
Health care providers with a woman-centered philosophy value closeness,
openness, and honest communication. Ruzek (1978) finds interactional patterns different
in feminist care centers. Communication patterns are more egalitarian and respectful
among care providers and women. An aura o f “woman-to-woman” connection is valued
in the professional relationship. Woman-centeredness respects the need for women to
have concerned women available in caretaking roles. All, but a few woman-centered
clinics, believe males with feminist values are appropriate team members, but there is a
consensus that women should always have the option for a woman caregiver.
Woman-centered values respect the role o f time and space in the health care
environment. Woman-centered caregivers believe time spent with women should be
sufficient to gain confidence and trust. Efficiency is not valued over quality relationships.
In addition, woman-centered care respects the spatial relationship between woman and
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caregiver, knowing the woman looses control o f the environment when she leaves the
privacy o f her home to receive health care. Woman-centered health care institutions value
the need to provide clinical spaces that give women a sense o f safety, control and
familiarity (Ruzek, 1978; Federation o f Feminist W omen’s Health Centers, 1981.
In addition, the work environment o f a woman-centered organization is often
different. Relationships among the woman-centered caregivers is based less on
hierarchical values judged by the person's education or role. Woman-centered health care
providers voice respect for the importance o f everyone’s contribution and are less
territorial in claim ing exclusive expertise, being willing to share knowledge with each
other. Woman-centered care providers value collaborative, consensus-based decision
making in the system (Iannello, 1992).
Values specific to women-centered childbirth evolved as childbirth activists o f the
‘’consumer movement” sought to re frame childbirth from a state o f medical pathology.
The overarching values o f woman respect, education, self-empowerment, and mutual
participation w ith birth attendants and caregivers are articulated in woman-centered
childbirth philosophies o f midwifery groups, childbirth educators, and childbirth
organizations and individual birth activists made up o f both consumers and professionals.
The totality o f past and more current birth activists illuminate a philosophy consistent
with woman-centered childbirth (Armstrong & Feldman, 1990; ASPO Lamaze, 1988;
Bradely, 1974; Doulas o f North America, 1998; Expert M aternity Group, 1993; Haire,
1975; Lamaze, 1958; Odent, 1992; 1994; Stewart & Stewart, 1979; Sullivan & Wertz,
1988; Young, 1982). The woman-centered philosophy o f childbirth common to these
birth activists is based upon respecting the wom an’s autonomy to have and choose among
birth alternatives and to support women, in varied ways, to resist modem medical control
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o f childbirth. Thus, woman-centered discourses that evolve through diverse birth
activists, individuals and organizations offer a perspective on childbirth that competes
with and decenters medical discourse for dominance in the birth culture.
These groups differ at various points over how to promote demedicalized birth
alternatives. Natural birth and prepared childbirth activists disagree in their approaches to
assist women to resist medicalized childbirth. For instance, midwives Armstrong &
Feldman (1990) and obstetrician, Michel Odent (1992; 1994), who promote natural
childbirth throngh holistic approaches, are critical o f the prepared childbirth principles
that focus on education to “control” birth. To holistic birth activists intellectually -
prepared birth plans or Lamaze breathing techniques undermine the innate and spiritual
connections necessary to give birth.
Likewise the integration o f woman-centered midwifery with feminist ideology is
often ambiguous and problematic. Some midwives believe the practice o f midwifery,
meaning “w ith woman,” is inherently woman-centered, although this is not always
clearly articulated as feminism (McCool & McCool, 1989; McLoughlin, 1997). Yet,
feminist midwives may not espouse all values consistent with traditional women or
spiritual midwives, concerning issues such as abortion and women’s role in the family
(Rothman, 1982). However in spite o f these conflicts, the childbirth philosophies among
the diverse groups are linked by an overriding ideology o f woman-centeredness.
Woman-centered philosophy o f childbirth represents “a caring, loving
acknowledgement o f the needs” o f childbearing women (Reid, 1997, p. 53). The
philosophy debunks the notion o f childbearing as essentially pathological and in need o f
medical intervention. Woman-centered philosophy holds up the experiences o f
pregnancy, birth and the puerperium as normal life events. Autonomy, self-care and
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independence are viewed as the right o f women. The women has a right to all information
to make informed choices and have access to childbirth education that contributes to the
empowerment o f women to choose among alternatives. A woman-centered approach to
childbirth recognizes that the social, psychological, physical and spiritual needs o f
parents affect birth and should be considered at all times.
Woman-centered philosophy acknowledges that women require assistance and
support by others, however, women possess an inner knowledge and strength that gives
them the wisdom and power to know how to give birth (Armstrong & Feldman, 1990;
Davis, 1997; Dwinell, 1992; Odent, 1992; 1994). Women-centered caregivers believe
their role involves assisting women to tap into their inner strength and protecting women
from a birth environment that demoralizes their efforts. Labor support that provides
emotional and comfort care by knowledgeable caregivers is considered essential. A
wom an’s significant and intimate others are believed to be defined by the woman, and
their participation in making decisions and providing support are determined by the
woman. Birth presents the potential to strengthen women’s spiritual and psychological
well-being and likewise to potentially traumatize women when needs are left unmet
surrounding birth (Madsen, 1994). Technology, obstetrical medical intervention and pain
medications are considered safe and appropriate options when a medical complication
warrants their use or if the woman freely chooses the intervention among alternatives
offered, within an atmosphere o f informed consent.
Operationalization o f Woman-Centered Care
The shifting o f power from the professional expert to the women/client that
alteres the balance o f authority and responsibility to one o f mutual participation is
operationalized through the actions o f feminist health care organizations and individual
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caregivers. Feminist health care systems attempt to change the relationship between
caregiver and woman/client by changing who provides care and the circumstances o f
care. Physical surroundings, care protocols, attitudes, and use o f time, technology and
education are among the considerations (Ruzek, 1978).
Settings that ensure a woman-centered atmosphere often employ predominately
wom en caregivers from diverse backgrounds in an attempt to reduce power and privilege
between the caregiver and the woman and promote an aura o f woman-to-woman support.
Nurse practitioners and nurse or direct-entry midwives are m ore frequently employed for
professional services than are physicians, who are more closely associated w ith
paternalist values. Nurse professionals are also thought to contribute to cost-effectiveness
o f wellness services. Physicians are available to consult for complicated cases or when
their technical or surgical expertise is indicated.
A nurse midwife or direct-entry midwife who embodies woman-centered
principles is considered positioned as “the best prepared birth attendants to care for
wom en in normal birth” (Cassidy-Brinn & Downer, 1984, p. 156). Midwives are skilled
in individualized, continuity o f care from antenatal to post-delivery. Their philosophy o f
birth centers on preserving the normalcy o f pregnancy and birth while offering guidance,
assistance or medical intervention when warranted (Davis, 1997; Skinner & Roch, 1995;
Rooks, 1997). Midwives assist wom en to tap into their inner strength to give birth by
attending to the holistic needs o f the woman and building confidence and trust in the
w om an’s ability to give birth. Care is adapted to the individual woman to elicit her
participation and sense o f responsibility.
In a professional relationship with woman-centered caregivers the health
assessment is a holistic process (Davis, 1997; Wheeler, 1995). The woman-centered
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health care experience begins with a health assessment that invites women to share the
context o f their lives that may impact their experiences in health, illness, or childbirth.
Communication and interactions are conducted to promote a trusting relationship that
m ay develop over repeated visits (Ruzek, 1978). The manner o f touch and examination
are respectful and caring. Touch during examination occurs after permission is obtained
and procedures explained. Invasive assessments are used only as deemed necessary for
care. Women are expected to review current research recommendations and reach
consensus with the caregiver regarding the frequency and appropriateness o f assessments
such as pap smears, mammography and routine antenatal tests. Woman-centered birth
attendants minimize invasive assessments such as ultrasound prenatal assessments during
pregnancy and vaginal examinations during labor, using less invasion ways to monitor
pregnancy and labor progress (Cassidy-Brinn & Downer, 1984). Education is assessed
and informed consent obtained before using equipment used such as speculums and fetal
monitors.
Time is operationalized in woman-centered care to offer the woman more
individualized care and personal control (Ruzek, 1978; Federation o f Feminist W omen’s
Health Centers, 1981. Clinic appointments are often scheduled for longer time intervals
than in traditional settings so the woman and caregiver are not rushed. In clinic settings
where the primary professional’s time is limited, lay caregivers, counselors, or nurses are
available to spend time as needed for specialized counseling and education.
The goal during woman-centered childbirth is to individualize care based on the
wom an/partner’s needs and desires, rather than routine practices. Using time to
m edicalize labor is challenged in woman-centered birth (Amey, 1982; R othm an, 1982).
Use o f pitocin induction, episiotomies and forceps are never used for the purpose o f
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speeding up the birth process, unless there are sound medical indications. F riedm an’s
(1954) labor tim e curve that normalizes tim e for each phase o f labor and dictates hospital
routines for each phase o f labor is resisted in woman-centered care.
Settings for w om an-centered health care and birth are planned around a
philosophy o f dem edicalization o f care. Settings are designed as com fortable, hom e-like
atm ospheres. Clinics or birthing areas attempt to separate them selves from
institutionalized decor, choosing hom e-like decorations, fem inine colors o r artw ork that
honors women. Institutionalized equipment, such as stirrups used for pelvic exam s o r to
assum e the lithotom y position for birth, is eliminated from routine use. Less restrictive
birthing beds or chairs are often offered to expand alternatives for birth positions o r
pelvic exam inations. U ltim ately it is believed women decide how to position th e ir bodies
to facilitate m utual needs o f the woman and caregiver during health care assessm ent or
birth. In w om an-centered childbirth the position for birth is focused on protecting the
w om an’s choice, unless complications warrant a change (Odent, 1994).
H ospitalized births, controlled by obstetricians, are constrained by policies that
dictate m edicalized practices and exert control over w om an-centered caregivers and
w om en-clients (A m ey, 1982; W ilson, 1996). Providing care in this setting often deterred
the ability o f the caregiver to provide woman-centered approaches to care and
necessitates the need for caregivers to assume an advocacy role to assist the w om an.
W om an-centered educators or caregivers either act to inform w om en o f other options for
birth settings, or w ork w ith the woman toward obtaining woman-centered alternatives to
m edicalized routines at hospitals. W oman-centered educators, m idw ives and nurses
advocate on b eh alf o f w om en’s wishes so that less restrictive approaches to birth care is
available. A dvocacy is accomplished through assertive com m unication techniques taught
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to w om en or used by caregivers on b eh alf o f w om en (M cKay, 1986). W om en are taught
how to go about developing a w ritten birth plan. Negotiation skills to use w ith the
institution or caregiver are taught and often em ployed by the w om an o r the w om an-
centered advocate on behalf o f the woman. T his process entails m aking com prom ises for
care that promote w om en’s autonom y and lessen m edical control o f birth. F o r exam ple,
w om en are often taught to negotiate for an intravenous heparin lock that provides
em ergency IV needle access, as opposed to continuous intravenous fluids that restrict
m ovem ent and represent excessive m edical intervention. A ccording to hospital standards,
certain technological equipment is required to b e present, such as suction, oxygen, fetal
m onitors, cardiac monitors, and neonatal w arm ers, however, hospitals are w illing to
deem phasize the clinical equipm ent by keeping it hidden or in the background unless
deem ed necessary (M cKay & Phillips, 1984; P hillips, 1994).
The potentially hostile hospital environm ent for wom an-centered birth
necessitates that w om en plan for extensive em otional and com fort support to prom ote
their ongoing autonom y at a vulnerable time. W hen a m idwife o r w om an-centered
physician is unavailable for the w om an during labor, the w om an is encouraged by
childbirth educators or other w om en w ho support her, to find a professional labor support
person, nurse, doula (lay caregiver), o r fam ily/friend who is know ledgeable and can
com m it to provide continuous support (D oulas o f N orth America, 1998; Perez, 1997;
Perez & Snedeker, 1990). Ideally this person has a professional o r personal relationship
w ith the woman prior to labor and is aware o f th e w om an’s w ishes and needs during
labor. Consum ers and nurses them selves recognize that nurses em ployed by hospitals are
restrained in their ability to perform w om an-centered care w hen the w om an’s w ishes
conflict with hospital or medical policy (A rm s, 1994; Diamond, 1996; H arper, 1994). B ut
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even the hospital nurse who desires and attem pts to provide w om an-centered labor
support is usually not available to stay past the assigned shift. Professional labor support
is suggested that w ill provide continuity o f care throughout labor. D oulas, caregivers w ho
are experienced and educated in com fort and emotional care o f w om en in labor, or
m onitrices, nurses w ho specialize in woman-centered labor support are an option.
Usually the woman is required to pay for the services o f independent labor support
outside insurance reim bursem ent, w hich can be a deterrent for som e w om en.
Free-standing birth centers are designed to offer wom en m uch m ore autonom y
surrounding birth. T hese settings are separate from hospitals and prom ote norm alcy o f
birth w ith caregivers w ho value a m idw ifery, woman-centered m odel o f childbirth (Ernst,
1996; N ational A ssociation o f C hildbearing Centers, 1995). U ltim ately, the home setting
is the m ore effective location to resist medicalization and provide the w om an and fam ily
with the autonom y to m ake decisions and control choices, such as the room , position, and
place for birth. Finding birth attendants for hom e birth rem ains difficult because home
birth is m arginalized as dangerous by the medical establishment. M any w om an-centered
caregivers, m idwives, and physicians provide underground services to w om en for hom e
birth, even though are under fear o f legal retributions in som e states. B irth attendants
ensure m edical backup in hospital settings in case o f medical em ergencies.
W om an-centered care includes the presence o f em pow ering health education th at
enables the w om an/fam ily to m ake inform ed decisions. W om an-centered education
provided by the health professional is based on making health education accessible to
w om en in “dem edicalized, clear language” (W hately, 1988, p. 131) that empowers
women to attain know ledge o f their bodies and self-care. The caregiver in turn learns
from the w om an as the w om an’s know ledge is affirmed through sharing her experiences
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with caregivers. Education offered within a w om an-centered philosophy provides the
woman w ith access to all possibilities o f care, including the undesirable consequences o f
treatm ents as well as the natural and radical forms o f curatives or alternatives (Ruzek,
1978). C lasses are designed to be informative and consciousness raising aim ed at the
feminist goal o f dem ystification, which means ‘th e process o f learning, applying and
sharing inform ation and experience to break down myths, misconceptions, stereotypes,
and fears" (T he Federation o f Feminist Health Centers, 1981, p. 103). Full access to
medical inform ation is available to the w oman. This includes providing test results w ith
clear interpretation o f all findings and with limitations o f the assessment findings. D uring
pregnancy and childbirth the woman is kept abreast o f h e r status and inform ed o f all care
interventions.
Co-Option o f W om an-Centered Care
M ore recently the promotion o f w om en’s health centers are m arketed by the
medical establishm ent. These imitations o f feminist health centers ignore the influence o f
the w om en’s health m ovem ent and act to co-opt the goals o f w om an-centered care. W ith
a declining birth rate, it became profitable to market w ide-range services to women.
W om en’s centers that are established and managed by hospitals are often disguised as
w om an-centered through sophisticated new spaper ads and posh buildings w ith fem inine
decor. The hospital or corporate-owned health care centers for women are presented as an
“ alternative w ithin the system ,” and must be evaluated for their usefulness to women
(W orcester & W hately, 1988, p. 124). Services are m arketed more directly to middle
class heterosexual w om en with private insurance. These clinics may offer no financial
assistance to the poor n o r accept w omen eligible for state o r federal aid. Therefore the
centers m ay not be available or sensitive to service all w o m en ’s needs. H ealth problem s
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specific to young w om en, poor w om en, women o f color, the elderly, and lesbians may
not be sufficiently addressed. Services also differ from feminist centers. Health education
program s offered are designed to target profitable services or technology offered by the
clinic, rather than empowering w om en to make inform ed choices from many options.
Options for care are lim ited to only physician practitioners and traditional medical
treatm ent modalities. On the other hand, manipulative advertisem ents may boast o f an all
female staff, but this alone is no guarantee o f a particular philosophy o r client autonom y.
W orcester & W hately (1988) believed “the concept o f consum er control is essential to
the fem inist demand for health care by women for w om en; medical control, even if by
women, undermines this goal” (p. 121). The potential fo r corporate clinics to be o f
service to all women is limited w ithout w om an-centered care principles.
The issue o f autonomy and physician paternalism have becom e more convoluted.
There are physicians who confront the issue o f paternalism by becom ing more skillful in
com m unication patterns that are developed to share inform ation w hile manipulating
women to choose medical interventions.
Likewise, the medical establishm ent continues to diffuse the woman-centered
birth movem ent. ACOG refused to w idely support birth centers and home births where
women and caregivers experienced m ore autonomy (N ational Association o f
Childbearing Centers, 1995). However, ACOG did support the creation o f hom e-like
birthing rooms in hospitals that im proved family participation and concealed m edical
technology within especially designed furniture (Interprofessional Task Force on Health
Care o f W omen and Children, 1978). This preserves th e obstetrician’s control o f the birth
setting and authoritative knowledge required to influence interventions. Physical changes
in the hospital setting did not alter m edical practices o r ensure a w om an’s birth
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autonomy. Ruzek (1978) refers to this as a m ove to “institutionalize highly
professionalized hom e-style birth" (p. 300). Through increased use o f technology and
surveillance, birth rituals and m edical control over birth practices proliferate in spite o f
concerted efforts and education by childbirth organizations and activists (Am ey, 1982;
Davis-Floyd, 1990; 1992; 1996; M cK ay, 1991).
Cultural A nalyses o f W estern Birth Practices
C hildbirth practices in W estern Culture evolve and change in response to larger
cultural trends. The establishm ent o f birth as a medical event is an expression o f
m odernization w here science, progress, and technology are valued for their potential to
control nature. The em ergence o f the m ale physician in the nineteenth century and the
struggle to establish the medical specialty o f obstetrics and gynecology in the early
twentieth century are prim ary forces that shaped the culture o f birth (B arker-B enfield,
1976; Leavitt, 1986; Sullivan & W ertz, 1988; W ertz & W ertz, 1989). T he m idw ife and
the hom e birth setting w ere the causality o f the m ale drive to control birth through
obstetrical practices and hospitalization.
Social Control o f Birth
The Flexner R eport o f 1910 set the stage for m edical reform that formalized
education and entry requirem ents necessary for the professionalization o f medicine.
Obstetricians used the im petus for m edical reform and the appeal for professionalization
to fuel their political and econom ic interests. The practice o f m idw ifery and com peting
discourses on the norm alcy o f birth w ere attacked to convince the m edical profession and
the public to accept the specialty o f obstetrics. This w as accom plished through organized
propaganda that presented the m idw ife as ignorant and untrained, and birth as dangerous,
pathological, and unpredictable. This propaganda set legislative restrictions on m idw ives ’
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practices, and eroded consum er confidence in them . American obstetricians left little
space for w om en midwives to practice in m ainstream medical culture. During the 1930s,
nurse m idw ifery was established to care for predom inately p o o r o r underprivileged
w om en w here there was no physician access.
Indulging in medical discourse that birth is pathological becam e problematic for
obstetricians since m ost births are normal. In contrast to A m erican obstetricians, British
obstetricians conceded the norm alcy o f birth and established boundaries o f norm al and
abnorm al pregnancy and birth. B ritish m idwives, although u n d er medical supervision,
continued to practice w ithin the boundary o f norm alcy. Rhetoric in American obstetrics
dealt w ith the problem o f norm alcy o f birth in a different m anner. Sociologist W illiam
A m ey (1982) believes American obstetrics cast birth in term s o f its potential for
pathology at any time, requiring the oversight o f the obstetrician to “ forsee pathology and
act prophylactically” (p. 51) ju st in case som ething might go w rong. According to A m ey,
tw entieth century obstetrics transform ed childbirth from a period o f confinement to a
period o f surveillance and m onitoring. Surveillance was presented as watching over the
interests o f the fetus-child and so ciety ’s interests.
O bstetricians assume responsibility for the social order o f birth. W om en’s
experiences surrounding pregnancy and birth are controlled through the choice o f
m edical practices considered acceptable. O rder and control is brought to birth through
routine use o f m edical procedures such as induction and episiotom ies, using tools like
forceps and medical technologies for m onitoring and surveillance. Birth positions, pain
m edications and anesthesia control the w om an’s mobility, participation, and m ental
aw areness o f the experience. Location o f birth, fam ily visitation policies and nursing care
routines are dictated by the m edical system (A m ey, 1982; H aire, 1972; M itford, 1992).
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A uthoritative Knowledge o f Birth
A nthropologist Brigitte Jordan’s (1993; 1997) cultural research analyzed the
social pow er o f the medical system to control birth experiences. Jordan’s ethnographic
study o f birth reveals how the construction and im plem entation o f authoritative medical
know ledge yielded control o f childbirth to the medical expert. T he pow er relations Jordan
studied concerning the modem delivery room scenario are dependent on a hierarchical
value o f knowledge. Medical know ledge represents suprem acy ov er other form s o f
knowledge, offered by nursing staff o r the birthing w oman. T his suprem acy o f medical
know ledge is acted out in birth scenarios studied by Jordan (1997). For example, the
w om an’s know ledge that she needs to push is not accepted at face value. O nly after the
vaginal exam does medical authority grant the wom an perm ission to push. O nce the
physician enters the room for delivery, all attention switches from the woman to
supporting the physician’s requests. Likewise, interactions in the room center on
com m unication am ong medical staff and nurses about the m edical data, w ithout directly
involving the w om an in data collection and analysis from her perspective. Jordan
believes such displays o f authoritative knowledge results in the w om an being designated
as object, dism issing her knowledge and limiting her participation and notion o f
achievem ent. Jordan recommends the need to develop ways to m ove from hierarchically
distributed authoritative knowledge into horizontally distributed knowledge. Jordan
believes horizontally distributed knowledge asks all birth participants to contribute to the
know ledge necessary for birth. The woman is able to participate in decision m aking, with
all participants involved in translation o f information. There is no competing knowledge,
but an application o f all forms o f knowledge to reach decisions. Jordan believes the
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potential for horizontally distributed knowledge serves as a challenge in developing the
ecology o f both low and high technology birth o f the future.
Technocratic Birth
A nthropologist Robbie D avis-Floyd (1990.1992, 1994, 1996) analyzes the
medical birth culture that characterizes the American birth process. D avis-Floyd’s (1992)
analysis reveals a paradigm o f birth she identifies as the “technocratic m odel o f b irth .” (p.
160). The birth rituals em bedded in the hospital delivery are analyzed for their enactm ent
o f society’s larger belief system . D avis-Floyd (1992) describes rituals as representing "a
patterned, repetitive, and sym bolic enactm ent o f a cultural belief o r value" (p. 8). D avis-
Floyd explains that rituals exist in culture to assist hum ans to find order, preserve the
status quo and provide the individual w ith cognitive structure around an internalized,
matrix o f symbols. The rituals serve as cultural symbols to send m essages em otionally
experienced as a gestalt. According to Davis-Floyd birth rituals fulfil this function.
Technocratic birth rituals (NPO, IV, continuous m onitoring, coached pushing) function
symbolically, sending the m essage that science and technology are necessary to give
birth. These beliefs reflect the broader philosophical m etaphor o f body-as-m achine,
evolving from D escartes’s m ind-body dualism . D avis-Floyd believes that birth rituals
enact the dominant b elief system that science, technology, patriarchy, and institutions are
considered superior to nature and w om en. Technocratic birth rituals provide protection
from the pow er and unpredictability o f nature as displayed in natural birth. D avis-Floyd
(1996) explains how participation in the birth rituals serves as a rite o f passage for
women to socialize them into the core cultural values:
.. .they [rituals] are enactm ents o f our culture’s deepest beliefs about the
necessity for cultural control o f natural processes, the untrustw orthiness o f
nature, and associated defectiveness o f the female body. T hey also
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reinforce the validity o f patriarchy, the superiority o f science and
technology, and the importance o f institutions and m achines. Furtherm ore,
these procedures are transformative in intent-they attem pt to contain and
control the inherently transformative natural process o f birth and to
transform the birthing woman into a w om an w ho has internalized the core
values o f Am erican society, (p. 307)
The effectiveness o f birth rituals in fulfilling this cultural role is evidenced in
D avis-Floyd's (1992) research where 100 wom en w ere interview ed about their birth
experiences. The largest num ber o f wom en, forty-tw o percent, described birth
experiences consistent w ith what Davis-Floyd (1992) identified as the category o f
"conceptual fusion with the technocratic model: w ith cognitive ease" (p. 219). The
w om en enter the hospital believing in natural childbirth, but actually experience
technocratic birth. The w om en’s perception o f their technocratic b irth is positive and
som ew hat em pow ering and they believe interventions are justified. A ccording to D avis-
Floyd's analysis, each w om an receives internalized m essages that th e body as m achine is
defective and requires help. Personal experiences successfully socialize the w om en to
believe that technological intervention is necessary for safe birth.
O f concern to D avis-Floyd (1992) was the nine percent o f w om en who
experienced cognitive distress after experiencing a technological birth, instead o f a
natural birth. These w om en experienced anger and psychological trau m a over losing
control o f their bodies and their birth experience. O n the other hand, eighteen percent
fully anticipated the technocratic birth and entered the experience w anting the m edical
system to control the event. Another twenty-five percent o f w om en interviewed w ere
em pow ered to m aintain distance from the technocratic m odel and eith er achieved "natural
childbirth" in the hospital o r carefully chose the interventions used. T hese women
m aintained a sense o f control over the birth event, based on their personal expectations.
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There were six percent o f w om en who identified with a holistic model o f birth
and preferred home birth with m idw ives. The w om en who had hom e births held strong
beliefs that childbirth is a "natural aspect o f w om anhood" or a "spiritual process o f
grow th" (Davis-Floyd, 1992, pp. 199, 201). The principles o f holistic birth articulated
through these w om en’s actions and beliefs are different than those o f technocratic birth.
U nlike technocratic birth, holistic birth represents cultural values that reflect w om an-
centeredness, m ind-body integration, m other-baby oneness and w elcom es norm al labor
processes. D avis-Floyd (1992; 1996) finds that postm odern holistic m others view their
bodies as a source o f feminine pow er, and voice no need to separate them selves from
their biology. However, the w om en do not represent a move tow ard w om en desiring to
return to a past era w here w om en’s identity was consum ed by the m othering capacity.
D avis-Floyd believes these w om en represented a postm odern w om an looking for a space
w here w om en’s gains during the m odem era can be accepted and celebrated along w ith
other attributes o f the feminine.
The technocratic model o f birth is the paradigm that encom passes hegem onic
beliefs about how birth should take place (D avis-Floyd, 1996; D avis-Floyd & Sargent,
1997). These hegem onic beliefs are held in power because patriarchal capitalist values
m ake m edicine a big business. D ue to American culture’s fear o f nature, and confidence
in m odem technology, an array o f m edical products are marketed for birth. The m edical
products promote a standardization o f technocratic birth among all hospital-based births
that m akes childbirth choices outside the technocratic model unavailable. W om en who
desire to step outside the technocratic m odel have to fight social forces for any space.
Births that reject the technocratic system , such as the hom e birthers w ith m idw ife
attendants, are labeled an act o f heresy. W omen w ho m ove too far from the technocratic
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model are often called “selfish” or “irresponsible” for endangering themselves and their
unborn. The w om en and their m idwife caregivers represent the fringes o f childbirth
culture and serve a purpose o f creating room for growth and change by challenging the
hegemonic beliefs that natural birth is dangerous.
D avis-Floyd (1992) believes attempts to change rituals can be a m eans o f
effecting social change. However, the possibility o f changing birth rituals is com plicated
by the legal and business systems o f society protecting these rituals. Beneficiaries o f the
technology m ovem ent in obstetrics include electronic m anufacturers who profit in
marketing technology and surveillance products and attorneys w ho create legal practices
around the interpretation and use o f technology. The ideology o f fetus as person/patient
also increases the legal risks o f m aking decisions based on w eighing m aternal vs. fetal
interests (Paola. 1998).
W agner (1994) refers to the proliferation o f birth technology as the “birth
machine,” that developed and thrived as a commercialized business. W agner believes the
thrust for obstetrical technology is driven by the physician, w ho helped design and create
dem and for its use in hospital and clinic settings. Commercial businesses m arket
technology as a m eans o f making profits for their companies. Technologies are often put
into w idespread use before the clinical benefits versus risks are clearly established, as in
the case o f electronic fet'd m onitoring (EFM) used in labor. Between 1965 and 1975
electronic fetal m onitors were introduced and m arketed by Corometrics M edical Systems.
It was not until 1976 that there was a legislative mandate to guide the testing and
evaluation o f m edical devices. Fetal monitors were in use fifteen years before a large-
scale study w as conducted on low risk women, indicating no medical benefit (Kunisch,
1989).
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W agner (1994) contends that technology w as not developed solely for the health
needs o f w om en and babies, but for the profession’s desire for technical expertise and
credibility. W agner believes a significant outcom e o f the birth m achine resulted in
w om en and their bodies being categorized as either high or low risk. Population data is
applied to individual w om en to predict outcomes. Such categorizations separate the
interests o f the fetus and mother, creates an “uneasiness about pregnancy and birth,”
(W agner, 1994, p. 98) stresses w hat can go wrong, and creates divisions am ong m edical
and nursing specialties. W agner argues that all interested parties, such as w om en, nurses,
m idwives, social scientists and health adm inistrators should have m ore input into the
utilization o f technology.
The influx o f technology in the 1970-1980s is a factor in th e sharp rise in
obstetrical lawsuits (Raines, 1985; Fetal Monitors O ffer Protection, 1997). The litigious
environm ent is fostered by the assum ption o f m odernity that technology should guarantee
good outcomes. These values in turn result in the legal establishm ent protecting
technocratic birth rituals, such as EFM. Once the technology entered routine use, medical
and nursing care standards are established. The legal system uses the standards to
evaluate client outcom es related to the technology’s proposed usefulness. Failure to
follow established standards o f care related to the appropriate use and interpretation o f
technology, including EFM, constitutes the basis for a m alpractice suit.
Once technology, such as EFM, was put into w idespread use it becam e difficult to
effect changes in practice. Although the American College o f O bstetricians and
G ynecologists’ (1995) revised standards o f care stating that interm ittent auscultation o f
fetal heart rate is a safe option to EFM in low risk pregnancies, th e m edical com m unity
still uses EFM for various reasons, identifying practical lim itations to auscultation.
I ll
Lim itations to auscultation identified in the medical literature include: the need for one-
on-one skilled nursing care, the possibility that auscultation data may not be recorded in
the chart, the difficulty o f ascertaining w ho is “ Iow-risk” and the element o f subjectivity
in palpation o f uterine patterns and hearing fetal heart tones. It is recommended by legal
experts and practicing obstetricians that good defensive m edicine includes the use o f
EFM as a screening tool so the obstetrician can validate reassuring patterns related to
fetal-wellness at all times (Fetal Monitors O ffer Protection, 1997; Young, 1995). T his, in
turn, perpetuates the routine use o f this technology for social reasons, beyond an issue o f
m edical safety alone (Raines, 1985; Roberts, 1985).
Social M ovem ents for Changing Technocratic Birth Norms
Birth activists and dissenters am ong the professional caregivers challenged the
m ovem ent tow ard technocratic birth practices sim ultaneous to its proliferation (B aker,
1978). However, over time, m ore organized m ovem ents started questioning and actively
changing the technocratic birth norms as universal practices for all women. C om m on to
these m ovem ents is an attem pt to recognize that normal pregnancy, birth, and fam ily
grow th with childbirth is possible with m inim al intervention, and alternative care and
caregivers outside o f a m edical model are viable options. T hese beliefs are reflected by
actions o f the following groups who challenged the technocratic paradigm as the norm .
W orld Health Organization
The W orld Health O rganization (W H O , 1985) has been concerned with the
im pact o f medical technologies on birth practices w orldw ide since the early 1980s. A s
W estern birth practices spread to developed and developing countries, global
im plications are recognized. Countries look to W HO (1985) for consultation regarding
the purchase and use o f birth technologies such as routine fetal ultrasound for prenatal
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screening. W H O staff recognize a need for global study and consensus on use o f
technology and its im plications on the health o f wom en, babies and communities
(W agner. 1994; 1997).
W HO (1985; 1996) established m ultidisciplinary perinatal study groups that
initiated a research-based review o f birth technologies and identified controversies that
evolved over the social versus medical orientation o f birth practices. With
recom m endations from this perinatal group. W HO sponsored and planned three
consecutive consensus m eetings in 1984, 1985, and 1986 to address the appropriate use
o f birth related technology (W agner, 1994). The consensus groups represented a mix o f
professionals w ith medical and social orientations, including epidem iologists, health
adm inistrators, bio-m edical engineers, m idw ives, nurses, obstetricians, pediatricians,
neonatologists, and social scientists. There w as an attem pt to balance the diversity am ong
developed and undeveloped countries and geographical regions, yet, the m en
outnum bered w om en. The participants researched assigned obstetrical practices prior to
the meetings, and presented their findings. T he m em bers debated the issues based on the
research presented and reached a consensus, m aking sum m ary recom m endations by the
end o f the m eeting.
Tw enty-one recom m endations were m ade by the 1985 W HO consensus group.
They agreed that the practice o f separating the well m other and normal newborn should
cease. The lithotom y position should not be used for birth and women needed
encouragem ent to freely m ove during labor. Routine medical procedures such as
episiotom ies, pubic shaving, enemas, routine induction, artificial rupture o f membranes,
and anesthetics w ere found scientifically unjustified. Goals for cesearean section birth
rates were set at ten to fifteen percent and for inductions at ten percent o f all births in a
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geographical region. It was recommended that fetal monitoring devices should only be
used in select high risk situations and that equipment purchases and w idespread use be
limited until more research validated its benefits. Overall concern for the prim acy o f the
social needs o f women experiencing childbirth was m ade manifest in the following
recommendation by W HO (1985):
Obstetric care services that have critical attitudes towards technology and
that have adopted an attitude o f respect for the emotional, psychological
and social aspects o f birth care should be identified. Such services should
be encouraged and the processes that have led them to their position must
be studied so that they can be used as models to foster sim ilar attitudes in
other centres and to influence obstetrical view s nationwide, (p. 3)
The sum m ary report (W HO, 1985) recom m endations were made based on the principles
acknowledging the w om an has a right to fully participate in all aspects o f care delivery
and that social, em otional, and psychological factors are prim ary in w om en’s care.
M ore recently in 1996, WHO again questioned developed countries’ continued
use o f interventions designed to “start, augment, accelerate, regulate, o r m onitor” norm al
birth (p. 1). This tim e childbirth experts from each region o f the w orld convened and
reviewed research evidence available concerning the efficacy o f com m on practices. In an
attem pt to once again define the norm s o f good practice for uncom plicated birth the
W HO “technical w orking group” com piled a document, Care in N orm al Birth: A
Practical Guide (1996). This time the working group classified its recom m endations on
practices related to norm al birth into four categories: (A) Practices w hich are
dem onstrably useful and should be encouraged. (B) Practices w hich are clearly harm ful
or ineffective and should be eliminated. (C) Practices for which insufficient evidence
exists to support a clear recommendation and which should be used with caution w hile
further research clarifies the issue. (D) Practices w hich are frequently used
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inappropriately (E nkin et al., 1995). Each recom m endation for care under the categories
is referenced to a sum m ary o f scientific research findings that support the g ro u p ’s
conclusions.
C oalition for Im proving M aternity Services
W H O ’s (1996) recom m endations for care in normal birth are consistent w ith
those developed in 1996 by the C oalition for Im proving M aternity Services (C IM S) in
the U nited States. C IM S consists o f a coalition o f national organizations and individuals
concerned for the care and w ell-being o f mothers, babies, and fam ilies. The m ission o f
C IM S (1996) “is to prom ote a w ellness model o f m aternity care that will im prove birth
outcom es and substantially reduce costs” (p. 1). T he wellness m odel is based o n research
and focused on “prevention and w ellness as alternatives to high-cost screening, diagnosis,
and treatm ent program s” (CIM S, 1996, p. 1). The m odel is based on principles centering
on the norm alcy o f birth, em pow erm ent and autonom y for w om en, avoiding interventions
that have risk, and recognizing the shared responsibility o f the caregivers, society, health
care institutions, and the individual wom an. The goal o f CIMS is to set standards and
designate birth settings as “m other-friendly.”
Ten Steps o f the M other-Friendly Childbirth Initiative (C IM S, 1996) guide birth
practices that support a wellness m odel o f care, as an alternative to birth controlled by
routinely em ployed practices and procedures. Sim ilar to the W HO recom m endations,
C IM S calls for labor support, m idw ifery services, freedom for birthing w om en to w alk
and assum e positions o f their choice, and the lim itation o f practices not supported by
research, such as intravenous drips, withholding nourishm ent, and continuous EFM .
C IM S set goals for a rate o f oxytocin use in labor o f no more than ten percent, episiotom y
rate o f tw enty percent, a total cesarean birth rate o f ten percent in com m unity hospitals
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and fifteen percent in tertiary care hospitals, and a vaginal birth after cesarean (V B A C )
rate o f sixty percent. Re-education o f professional staff to learn labor support and to
prom ote W HO initiatives for successful breastfeeding, m other and fam ily contact w ith
the new born, and cultural sensitivity are encouraged.
The D oula M ovem ent: Doulas o f North A m erica (DONA)
O ver the past decade there has been m ovem ent to re-institute w om an-helping-
w om an in labor b y providing continuous em otional and com fort support to the w om an.
The shift to hospital births by the 1950s elim inated the w om an caregiver that traditionally
attended to the w om an throughout her labor. The hospital system rarely provided a m odel
o f care w here the nurse could give her undivided attention to one w om an throughout the
entire course o f her labor. Thus, the lack o f labor support in a highly technocratic
environm ent left w om en further alienated and unable to achieve their goals for natural o r
prepared childbirth. To offset this trend, w om en caregivers came forward offering one-
on-one labor support, calling themselves a labor coach, monitrice, o r childbirth assistant.
Klaus, K ennell and Klaus (1993) use the G reek word “doula,” m eaning “w om an-servant”
(p. 4) in a renew ed and more direct m ovem ent to provide w om an-to-w om an help during
or after birth. The doula has come to be recognized as a “ supportive com panion (not a
friend o r loved one) professionally trained to provide labor support” (D oulas o f N orth
A m erica, 1998, p. 1). Postpartal doulas m ay also continue the relationship after birth to
assist w ith early m othering needs. Doulas consider themselves advocates for the w om an
to support her birth and m othering goals and protect the wom an from a potentially hostile
hospital birth environm ent (Hotelling, 1998).
This renewed m ovem ent is sparked by research dem onstrating that continuous
labor support by another w om an shortens labor, reduces cesearean birth rates and
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prom otes the w om an’s sense o f accom plishm ent and self-esteem that further aids her in
m othering the infant (Kennel!, K laus, M cGrath, Robertson, & H inkley, 1991; Klaus,
Kennell, Berkowitz, & Klaus, 1992; Klaus, Kennell, Robertson, Sosa, 1986; M artin,
Landry, & Steelman, 1998; Sosa, K ennell, Klaus, Robertson, & Urrutia, 1980). DONA
w as founded in 1993 by childbirth educator Penny Simkin to establish standards for
education and training o f doulas and to unifty the movement. D O N A ’s m em bership
exceeds 2000 m em bers, and in a y e ar the organization provided 3500 referrals to
consum ers seeking information (Szalay, 1998). T he organization works on overcom ing
barriers to providing doula services, including econom ic issues, such as third party
reim bursem ent.
R enaissance o f Midw ifery (Nurse & Direct Entry)
There is a renewed interest in prom otion o f m idw ifery to provide w om en-
centered, non-interventionist approaches to care. W HO (1985, 1996) and CIM S (1996)
support the m idw ife as the most appropriate caregiver for w om en who experience normal
pregnancy and birth. W HO (1996, p. 4) recognizes the m idw ife as the caregiver that can
provide the care w hen the aim is “to achieve a healthy m other and child w ith the least
possible level o f intervention that is com patible w ith safety.” W H O (1996) supports the
following international definition o f the midwife: “ if the education program m e is
recognized by the governm ent that licenses the m idw ife to practice, that person is a
m idw ife” (p. 5). The midwife, as a skilled caregiver during childbirth, m ay differ
throughout the world in educational preparation, training, and scope o f practice. M any
m idw ives work independently in th e com munity, home, and birthing centers, o r as typical
in the United States, m any work alongside obstetricians in hospital settings. Yet, the
overriding values o f wom an-centered care that focus on the social and biological context
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o f childbearing as a normal life event makes the m idwifery m odel o f care m o st effective
in reducing medical intervention.
Unlike the past, midwives today have scientific evidence to validate th eir
practices. Research regarding the outcom es o f m idw ifery sendees supports th e benefits o f
the m idw ifery m odel o f care. Research validates that midwife attended births result in
im proved outcom es w hile decreasing frequency o f cesarean births and episiotom ies
(B utler. Adams, Parker, Roberts, & Laros, 1993; Greulich, Paine, M cClain, B arger,
Edwards, & Paul, 1994). Birth centers with m idw ives on staff are considered safe and
econom ical (Rooks et al., 1989). The thrust for cost containm ent in m anaged care
organizations increases the interest in using m idw ifes to decrease costly and unnecessary
interventions (Bell & M ills, 1989; Em st, 1996). W om en giving birth w ith m idw ives
voice satisfaction w ith the autonom y and em otional support afforded them w ith in a
w om an-centered ideology (Kennedy, 1995). In 1997, midwife attended births represented
7.0% (272,201) o f all U.S. births, m ore than double the num ber o f births attended the
previous decade (V entura et al., 1999).
Tensions w ithin organized m idw ife groups led to expand options for education
and certification for the different types o f m idw ives in the U nited States. The M idw ives
A lliance o f North A m erica (M ANA, 1997) was founded in 1982 to prom ote m idw ifery in
the health care system in North A m erica and unite the interests o f all m idw ives focusing
on the specific needs o f the direct-entry and lay m idwife. In 1994, M ANA founded the
N orth A m erican R egistry o f M idw ives (NARM ) that examines and certifies th e direct-
entry’ m idw ife called the Certified Professional M idw ife (CPM ). The legal status o f the
CPM varies am ong states (M ANA, 1997; Rooks, 1997).
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Likew ise, in 1994, the American College o f N urse-M idw ives (A CN M ) supported
credentialing o f non-nurse direct-entry m idw ives, called certified m idw ives (C M ). The
certified m idw ifery (CM ) education programs w ere required to offer a baccalaureate
degree or require a baccalaureate degree as a prerequisite in order to further the scholarly
and research pursuits o f the profession, although a nursing degree w as no longer required
(A C N M , 1997; Rooks, 1997).
The actions by the ACNM and M ANA dem onstrates a w illingness to m inim ize
barriers to educating and certifying midwives so m ore m idw ives can be available to care
for w om en and babies. However, this strengthens the debate on w hether m idw ifery -
should continue its relationship w ith the nursing profession. M uzio (1991) contends
m idw ifery education is disadvantaged by its association w ith nursing education.
A ccording to M uzio, nursing education traditionally focuses on passive, neutral learning.
The nursing profession does not incorporate fem inism , holism and student autonom y into
the nursing curriculum , all o f w hich are im portant to m idw ifery education.
The U nited K ingdom w orked to reform m aternity services offered by m idw ives.
The Expert M aternity G roup (1993) was established by the N ational H ealth Services to
set goals, outline actions for reform , and conduct a five-year evaluation. The E xpert
M aternity G roup identified its prim ary initiative for reform as m aking m aternity care
w om an-centered, concentrating on the needs o f the woman. This m eant increasing
professional independence for midwives, prom oting client autonom y, decision-m aking
and birth planning that also included home birth as a viable option. The principles used
by the Expert M aternity Group (1993) to guide “good m aternity care” included:
The w om an m ust be the focus o f m aternity care. She should be able to feel
that she is in control o f w hat is happening to her and able to m ake
decisions about her care, based on her needs, having discussed m atters
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fully w ith the professional involved. M aternity services must be readily
and easily accessible to all. They should be sensitive to the needs o f the
local population and based prim arily in the com m unity. Women should be
involved in the m onitoring and planning o f m aternity services to ensure
that they are responsive to the needs o f a changing society. In addition
care should be effective and resources used efficiently, (p. 8)
Sum m ary
In this section I review ed the cultural, political, and social influences on w om en’s
reproductive health care. I highlighted the advancem ents m ade through second wave
fem inism that opened the possibility for w om an-centered care. I reviewed fem inist and
health care literature to describe the philosophical tenets and practices associated with a
w om an-centered philosophy o f health care and m aternity services. I presented social and
cultural analyses o f W estern birth practices to dem onstrate how dominant discourses
continue to exert pow er over w om en’s experiences. I described current social m ovem ents
that challenge dominant discourses and health care practices. These social m ovements
offer renew ed hope for the im provem ent and diversification o f maternity care. In this
section I celebrated the past efforts o f the fem inist m ovem ent to affect changes in
w om en’s health care experiences while I illum inated the patriarchal nature o f health care
that continues to require challenge and resistance so that gender-sensitive care will be
possible. In the next section I continue w ith a critique o f the nursing profession and the
m aternity nursing specialty to identify how nursing practices have acted to both uphold
and resist hegem onic discourses that define w o m en ’s reproductive health care. This
critique supports the need for reform in the education o f maternity’ nurses consistent with
the care values o f a woman-centered philosophy. I begin w ith a historical overview o f
how the nursing profession interfaces with fem inism and postm odernism .
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Nursing and Feminism
How feminism and nursing can com plem ent each other in a com m on cause to
im prove health care for women, families, and society is yet to be fully realized.
Traditionally it was dom inant patriarchal discourses, not feminisms, that directly
influenced the know ledge development, education, practice, and research endeavors o f
nursing (Dickson 1992; Doering, 1992; W uest, 1994). M odem nursing has long been
stereotyped as a profession that epitomizes subservience o f w om en to institutions and
patriarchal authority in a traditionally gendered caretaking role. The history o f nursing
has supported this image through the reality o f oppressive education, role socialization
and w orking conditions o f nurses (Ashley, 1976; Reverby, 1989). This alignm ent with
the patriarchy made nurses ill-equipped to w ork for their em ancipation o r for that o f the
w om en in their care. In the late twentieth century feminist nurses emerged who sought to
reinject feminist ideology in nursing, to envision possibilities and to establish a nursing
praxis grounded in fem inist beliefs.
This section overviews nursing’s historical relationship with feminism and the
m ore recent resurgence o f feminist ideology in nursing practice and education.
Postm odern theory is overview ed in relation to how nurses perceived its usefulness in
critical analysis and em ancipatory nursing practice.
N ursing: Fem inist Roots and the Patriarchy
Early nursing has roots in feminist values and radical women. Roberts & Group
(1995) characterize nursing and feminism as having a short period o f co-existence with
first-w ave feminism o f the early twentieth century. Feminist historians contrast
N ightingale’s popular image o f “the lady with the lamp” called into service by God, to
the woman as a spiritual feminist who rejected domestic life in the Victorian era seeking
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an alternative reality for wom en and “wrestled control o f nursing from m en" (R oberts &
Group, 1995, p. 19). W hile N ightingale is criticized for not fighting for w om en’s rights
and suffrage, she strove for em ancipation o f w om en to free them selves from Victorian
constraints. But as N ightingale opened the way for women to e n ter paid labor, she
dem anded that w om en m ake a choice between hom e and career and denied that gender
was a barrier to a w om an’s success. N ightingale’s “contorted v ariety ” (Forster, 1984, p.
124) o f fem inism caused h er to be characterized as a “borderline” fem inist (A llan, 1993,
p. 1551). Her m ore radical feminist w riting, the essay Cassandra, w as not published
initially due to the recom m endation o f powerful m en who supported her projects and
feared the effects feminist writings m ight have on her work.
D uring the early tw entieth century other w om en leaders in nursing em erged who
are better recognized as feminist activists who worked for social changes for w om en and
im proved health care for the poor and diverse ethnic groups. N ursing provided a route
through which “ fem inism , social reform and nursing came together” (Poslusny, 1989, p.
64). W om en such as Isabel H am pton Robb, Lavinia Dock, and M ary Adelide N utting,
were fem inist friends and nurse leaders who battled patriarchal social structures that
im pacted health care and the w orking condition and education o f nurses. Lillian W ald,
the founder o f public health nursing, fought social and gender injustices through her
com m unity activism and establishm ent o f the Henry Street S ettlem ent House in New
York. Clara Burton, who organized the American Red Cross, w as know n as a civil
libertarian, involved in w om en’s rights issues. M argaret Sanger began the m ovem ent for
reproductive freedom as a result o f her nursing experiences w ith p o o r women.
The fem inist them es o f these early leaders remain relatively silenced in nursing
history and the public im age o f nursing (Roberts & Group, 1995). W om en such as Sanger
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had to separate them selves from nursing to accomplish their w ider social goals. Even the
nursing profession rem em bers N ightingale more as a researcher, environm entalist,
adm inistrator, and the founder o f nursing, rather than for h er attem pts to seek cultural
freedom for women.
W ith strong roots in early feminist movements there are m any reasons postulated
as to w hy nursing as a profession failed to em brace fem inist visions during its early
establishm ent, and thus rem ained under strong control and influence o f patriarchal
discourses throughout the tw entieth century. By the 1980s nurses identified them selves as
an oppressed group in need o f liberation (Hedin, 1986; R oberts, 1983). B unting &
C am pbell (1990) calls for nurses to move toward understanding and valuing the
“interw oven com plex history” (p. 23) that results in close ties with the patriarchy. The
dilem m a o f nursing is tied to broader issues o f class and gender that affect all women.
The m ale-m odel o f professionalism , the devalue o f care, service and w om en in a
capitalist society, and the diversity o f class and educational preparation th a t prevented
nursing unity are am ong the reasons why nursing failed to em brace fem inist visions
(Ashley, 1976; Bent, 1993; Bunting & Campbell, 1990; H agelle, 1989; R everby, 1987;
Vance, T albott, & M ason. 1985; W uest, 1994).
T he societal devaluation o f wom en and nurses in traditional caring roles is
identified as a dilem m a fem inists and nurses have not sufficiently addressed (Baer, 1991;
Gordon, 1991, 1997). R everby (1989) believed the oppression o f w om en nurses began as
they w ere called to a d uty to care in a society that did not value care. The duty to care
im posed self-sacrifice for the ideal o f altruism as nurses w ere educated to be disciplined
soldiers. A m erican hospitals developed as business endeavors, requiring labor from
women in order to succeed. H ospitals represented patriarchal system s influenced by the
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military and church that resulted in a nursing code o f ethics to serve physicians. A public
campaign by physicians successfully positioned themselves as “captain o f the ship,”
(Lynaugh. 1988, p. 29) convincing hospital administrators, nurses, and society o f their
authoritative knowledge. N urses were “ordered to care” in hospital environm ents
embedded in masculine logic, preventing equality and autonom y for nurses in the system .
Hospital organizations w ere designed and functioned as bureaucracies valuing
hierarchical relations, rules, and depersonalization in w hich nurses w ere socialized to
accept as the norm (Ashley, 1976; D avies, 1995). Professional m odels that depended on
the hospital environment for the education and practice o f nursing w ere not com patible
w ith feminist ideology. N ursing endeavors that used fem inist-socialist perspectives w ere
usually confined to com m unity-based services, like those pioneered b y Lillian W ald.
Following the physician’s m edical model toward professionalism seem ed the
m ost practical thing to do. Nursing sought the same prestige and pow er afforded
physicians through this m odel. In retrospect, the dom inant m ale m odel o f professionalism
has been shown to be inadequate for the practice and study o f nursing w ith its hum anistic
focus (Baer, 1991, Davies, 1995; D oering, 1992; Hagelle, 1989; W uest, 1994).
Knowledge valued in the m odem medical profession focuses alm ost exclusively on the
positivist/em pirical view, w hich is assum ed to be the only w ay to th e fixed “truth.” This
mechanistic model under the Cartesian view separates m ind and body, causing a
disem bodied view o f the s e lf (B enner & W rubel, 1989). O bjectivity and neutrality are
valued over understanding experiences in health states and hum an relationships in care.
Hierarchical relationships and ownership o f knowledge inherent in professions restricts
the nurses’ ability to form and value hum an relationships w ith patients. A dditionally the
structured m isogyny em bedded w ithin society is a deterrent to nursing gaining
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recognition desired in this model (Ashley, 1980). Paternalism and sexist attitudes prevail.
T he b elief that w om en were ‘“other,” translated as inferior or less im portant than m en,
repeatedly em erges in nursing’s struggle for funding fo r higher education and autonom y
in nursing practice (Roberts & G roup, 1995).
Feminist ideals that influenced early nursing leaders faded w ith the search for
professionalism . N ursing leaders w ho sought au to n o m y for w om en were not alw ays
supported by the rank-and-file nurse. The diversity o f class and educational levels, as
collegiate education became an option, made unified com m itm ents difficult (Reverby,
1987). Likewise internal divisions among nurses w ere evident as A frican American
nurses fought both sexism and racial discrim ination w ith in bureaucratic organizations.
A frican American nurses fought for recognition from th e predom inately white, female
profession and to be equal peers in nursing organizations (Hine, 1989).
T he Resurgence o f Feminism : A C all for Critical C onsciousness in Nursing:
Nursing scholarship reflects a gradual reintroduction o f fem inist ideology
throughout the 1980s-1990s. Fem inist group process is used to challenge more
hierarchical ways o f interacting w ith others (W heeler & Chinn, 1991). Fem inist nurse
scholars propose critical consciousness raising to reconceptualize and activate nursing to
m ove beyond dom inant ideology that restrains p ractice and research (Ballou & Bryant,
1997; Bent, 1993; Cheek & Rudge, 1994a; Chinn & W heeler, 1985; Henderson, 1997;
M ason, Backer, & Georges, 1991; Sampselle, 1990; T hom pson, 1987). Feminism and
critical consciousness raising offers nursing the potential for seeking and producing new
know ledge and acting on that know ledge for individual and social change (Henderson,
1997; W ilson-Thompson, 1995). Consciousness raisin g provides nursing scholars an
opening for critical analysis o f the im pact o f hegem onic discourses on nursing
know ledge. The distribution o f pow er w ithin professional know ledge and nurse-patient
relationships is exposed as problem atic. Critical consciousness raising is proposed as a
nursing action to develop fem inist em ancipatory nursing practice. This is theorized to
occur through nurses’ increased awareness o f the social and historical dom ination that
im pacts the health care status o f individuals and groups (K endall, 1992). T his call for
critical consciousness extends the notion o f environm ent w ithin nursing theory and
practice to include the social context in w hich health and illness occur (B utterfield. 1990;
Kleffel, 19 9 1). As a practice discipline, it is inadequate to only deconstruct and critique
social influences on nursing and health. N ursing praxis requires actions aim ed at
changing the status quo. Fem inist research m ethodologies are used for th eir potential for
em ancipatory goals for the researcher and the participants (H enderson, 1995; Sigsworth,
1995). H ow ever, the outcom e o f feminist nursing praxis has yet to be fully evaluated.
M ore research is recom m ended to further study the differences in health care though
fem inist action (M cCorm ick & Roussy, 1997; Speedy, 1997).
Likew ise, feminist nurse educators seek to raise th e consciousness o f teachers to
the possibilities o f feminist pedagogy in nursing education (M cGehee, 1993). Fem inist
teaching m ethodologies are recom m ended to change the oppressive nature o f nursing
education and establish m ore egalitarian relationships w ith students (H edin & D onovan,
1989). Fem inist pedagogy acknow ledges the experiences o f predom inately w om en
students, facilitates personal em pow erm ent w ithin nursing education and challenges the
assum ptions o f traditional pedagogy (Chirm, 1989; D iekelm ann; 1997). C ritical
pedagogies are recom m ended to teach em ancipatory nursing actions that consider how
gender, race, class, and patriarchal bureaucracies impact health. Critical pedagogies are
thought to prom ote student n urses’ self-awareness o f oppressive nursing practices that
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control client decision-m aking and treat clients as objects (Harden, 1996; V arcoe, 1997).
W ith an increased focus on com m unity-based nursing practice, fem inist-critical pedagogy
is recognized as the m edium to prepare students to change oppressive health care
conditions for individuals and com m unities (Patsdaughter, Hall, & Stevens, 1996;
W alton, 1996).
W idespread application o f teaching strategies consistent w ith fem inist-pedagogy
is m ore predom inant w ithin w om en’s health courses taught as electives at the
undergraduate level or w ithin w om en’s health courses taught in graduate level courses
(A ndrist, 1997b; M orse, 1995; R uffing-Rahal, 1992; Valentine, 1997; W alton, 1996).
O nly B reslin (1995) reports integrating w om en’s health concepts w ithin an undergraduate
m aternity course based on feminist perspectives. Fem inist pedagogy is reported by nurse
educators to connect learning to personal lives, prom ote autonomous attitudes, and
socialize students into feminist practices that advocate for the health concerns o f w om en
(B oughn 1991; B oughn & W ang, 1994; H ezekiah, 1993; Thomas, 1992). W eyenberg
(1998) criticizes fem inist pedagogy as having a privileged but limited status w ithin
nursing education, since the use o f feminist strategies is not the norm in core courses
across m ost nursing curricular. Teachers using strategies consistent w ith fem inist
pedagogy are m ore likely to teach small graduate sem inars in w om en’s health.
W eyenberg believes the em ancipatory potential o f fem inist pedagogy over traditional
educational strategies, and the com plexities o f practicing feminist pedagogy w ithin
bureaucratic, hierarchical educational institutions, rem ain concerns fo r study.
Postm odernism w ithin N ursing:
Like other disciplines there is debate within nursing over the application o f
postm odern theories. Reed (1995) is skeptical o f postm odernism , believing this ideology
offers too m uch critique and not enough action to facilitate nursing knowledge
developm ent. Reed cautions against a postm odernism that w ould separate nursing from
the hum anistic m etanarrative. Zbilut (1996) questions the postm odern trends o f
interpreted ve nursing research as a threat to the scientific basis o f the discipline. In
contrast, W atson (1995), Lister (1997), and Emden (1995) indicate hope that
postm odernism m ight serve as a lens through which nursing can critique dom inant
W estern philosophy and reconnect know ledge to the human condition. Fahy (1997)
argues that postm odernism was not a rejection o f hum anism , but exposed how hum anism
acts to norm alize behavior and control subjectivity. Fahy believes postm odernism is
com patible w ith politically-based hum anism . M cCorm ick and R oussy (1997) believes
postm odernism enhances the critical stance o f feminism as nursing praxis. The po w er o f
discourse and language in nursing theories and the w ider androcentric, ethnocentric and
class bias em bedded in nursing practices are exposed through postm odern perspectives.
C heek and R udge (1994b) and Doering (1992) found Foucault’s (1975/1977) theory o f
pow er and know ledge useful to dem onstrate the socio-political context in which nursing
operates. Foucault’s writings are used to understand how nursing operates to control
practice know ledge through discourse and participates in disciplinary techniques in
practices. H ickson and Holmes (1994) use a postmodern analysis o f pow er to reveal the
concept o f the “ good patient” as the disciplined, obedient body o r the “good nurse” as a
docile, self-policing nurse who adheres to rituals. Cheek and G ibson (1996) expose the
pow er relations w ithin discourse and rules surrounding m edication adm inistration that
reduce nursing w ork to a series o f steps and viewed the person/patient as object.
R eflective questioning and deconstruction o f the m echanisms o f pow er exposed through
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postm odern thinking are useful for th e ir potential to reshape future nursing fram ew orks to
be less oppressive to nurses and patients.
Summary
I introduced the feminist roots and patriarchal influences on early nursing that
subsequently influenced the status an d w orking conditions o f nursing. I acknow ledged
the patriarchal influences within society and the health care system that acted to control
and oppress nursing as prim arily a w om en’s profession. I presented a hope for critical
consciousness in nursing through the recent resurgence o f feminism as reflected in
nursing scholarship, practice and education. I contrasted the possible limitations and
benefits to using postm odern perspectives w ithin nursing theory and practice. The
possibilities evidenced through nursing’s relationship w ith postm odem -fem inism opens
hope for using such theoretical underpinnings as nursing praxis in teaching wom an-
centered maternity nursing.
M aternity N ursing
Professional nurses assumed the role o f prim ary caregivers o f women throughout
the hospitalized maternity experience. As prim arily w om en em ployed by patriarchal
health care systems, maternity nurses face the conflicts o f caring for w om en and babies in
environm ents designed and managed by “ m asculine logic” (Davies, 1995, p. 51). In this
section I explore the relationship that developed betw een obstetrical m edical practice and
the m odem maternity nurse in the health care environm ent. I describe the impact o f
external forces on m aternity nursing practices, such as the w om en’s health m ovem ent,
technological revolution, and m anaged care. M ovem ents made by m aternity nursing to
work w ithin and/or outside the dom inant system to preserve or enhance humanistic
childbearing practices are integrated into the discussion o f external forces. Lastly, I
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broadly overview dom inant discourses that represent current m aternity nursing
know ledge. I do this through a cursory review o f perspectives articulated in current
m aternity textbooks that represent the discipline.
H istorical Roots in Obstetrics
The role o f nurses is virtually invisible in historical accounts o f childbirth.
Historians Wertz & W ertz (1989) rarely m ention the distinct role o f nurses in m aternity
care in the early tw entieth century. They describe nineteenth century nurses as untrained,
practical helpers w ho acted as a hired servant o f the family to clean up, run errands, and
obey the male doctors. Florence N ightingale upgraded nursing to an educated profession
and attracted young w om en to the profession. W ertz and W ertz (1989) depicted
N ightingale’s establishm ent o f the nursing profession as being detrim ental to attracting
w om en into medicine to care for w omen during childbirth as trained physicians.
By the 1920s and 1930s care by professional nurses w as considered by historians
to be one o f the enticem ents for hospital birth. O bstetricians w ere establishing them selves
as birth experts and the trend tow ard hospital b irth s had begun. A long w ith drugs for
tw ilight sleep, the availability o f tw enty-four h o u r a day trained nurses w as p art o f the
advertised enticem ents for hospital birth (W ertz & Wertz, 1989). H ospital-based nurses
w ere em ployed to care for wom en during birth and in the lying-in wards, w here w om en
stayed one to two w eeks after birth to recuperate. The nurses w ere assigned to care for
w om en w ithin the com partm entalized areas established by m edical obstetrics. Labor and
delivery, lying-in w ards, and new born nurseries evolved as obstetrics attem pted to
im prove hospital births and control infections b y isolating babies and m others (Leavitt,
r
1986 ).
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From the beginning o f hospital-based m aternity care, nurses and obstetrical
m edicine w ere closely tied. Nurses were educated in the rationale for obstetrical
procedures and were expected to provide nursing care to support the safe implementation
o f a medical m odel o f birth and recovery. Dr. DeLee, an obstetrician renowned for
advocating interventions such as forceps births and episiotom ies, constituted him self as a
teacher o f obstetric nursing. His text, D eLee’s O bstetrics for Nurses (D avis & Carmon,
1944), underw ent num erous revisions during the first h a lf o f the tw entieth century as it
w as used to educate nurses to care for w omen and babies w ithin the m edical specialty o f
obstetrics. T he im portance o f nurses to the medical practice o f obstetrics was sum marized
in an introductory chapter in DeLee’s Obstetrics for N urses, edited by Davis & Carm on
(1944):
M odem obstetrics depends to a great extent on a thoroughly trained

nursing sta ff.. ..The nurse has assumed a most im portant place in our
specialty. She provides the keystone for the m agnificent edifice w e have
built for the care o f our mothers and babies. She runs the m odem
m aternity w ith its com plicated arm am entarium. H er special skills are
exercised in the care o f patients, in the delivery room s or in the
n ursery— She is the teacher who brings the patient in tune w ith present
day obstetrics. In her role as public health nurse she visits the patient in
her hom e and can study the many problem s o f the family environm ent.
She is the friend and counsellor o f the patient during a m ost im portant
period in her life....S h e is the physician’s assistant and team m ate under
the stress and strain o f medical practice. Verily, she m ust be a dozen
w om en in one to be a successful obstetric nurse, (pp. 6-8)
B eing referred to as an “obstetric nurse” signifies a close relationship and
identity to th e m edical field o f obstetrics. To the present day, nurses w ho care for
w om en and babies during childbearing continue to identify them selves as
obstetrical o r “ O .B .” nurses. W hen “perinatology” evolved as the high-risk
m aternal-fetal obstetrical specialty in the 1970s, nurses w ho cared for “high-risk”
pregnant w om en followed suit by calling themselves perinatal nurses (N urses’
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A ssociation o f the Am erican College o f Obstetricians and G ynecologists, 1979).
A few nurses criticize language that continues to tie m aternity nursing to the
m edical specialty o f obstetrics. Phillips (1996) recommends m aternity nursing as
a better description for the “system o f care in which the nurse collaborates w ith
the childbearing fam ily,” (p. 2) as opposed to obstetrics, w hich means, “to stand
before” in a position o f authority and control.
The close bond between nurses and obstetricians in the care o f childbearing
w om en culm inated in A CO G founding The Nursing Association o f the A m erican College
o f Obstetricians and Gynecologists (NAACOG) in 1968. A C O G initially funded
N AACOG as the first nursing specialty organization “to be established under the auspices
o f a national m edical specialty organization” (W ohlert, 1979, p. 10). N A A CO G members
elected their own officers, with the organizational bylaws based on A CO G ’s model.
N A ACO G worked in cooperation w ith ACOG to establish standards o f care and nursing
continuing education. It would not be until 1993 that NAACOG was officially dissolved
and the Association o f W om en’s Health, Obstetric, and Neonatal Nursing (AW HONN)
w as established as the professional nursing organization, independent o f A COG . This
m ove was recognized as action to promote a more collaborative relationship w ith ACOG,
as opposed to the hierarchical, “parent-child” relationship that had existed (H aller, 1993,
p. 14). “W om en's Health” replaced the word “gynecology” in the association’s name as a
com m itm ent tow ard defining and promoting w om en’s health throughout the life span, yet
“obstetric nursing” was retained.
The close association between obstetricians and obstetrical nurses assist in
institutionalizing childbirth as a series o f medical and nursing routines that w orks in
concert (Amey, 1982). Fem inists criticize the relationship betw een obstetricians and
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nurses. Daly (1978, pp. 276-277) suggests nurses are employed to be the “token
torturers,” o f w om en patients, being “trained to be totally obedient to the O lym pian
D octor” to act as the “visible agent o f painful and destructive treatm ent.” Fem inists
generalize that socialization o f nurses and their employment by hospitals contributes to
nurses’ com plicity w ith obstetricians to create and sustain the m edical model o f birth
(A rm s, 1994; Barker-Benfield, 1976; Ruzek, 1978).
This generalization does not consider the often covert actions by individual nurses
to circum vent the m edical system by altering physician’s orders. A ctions such as telling a
w om an she had the rig h t to refuse the m edication o r treatm ent is a w ay for nurses to offer
w om en alternatives to the m edical plan, w hile avoiding direct confrontation w ith
authority (Sandelow ski, 1981). T he fem inist criticism failed to acknow ledge the efforts o f
individual nurses w ho w ork w ithin the system to offer wom an-centered experiences to
w om en in their care and the lack o f action o f w om en/clients to assum e responsibility for
their education and birth planning necessary to m aking choices. N u rses’ socialization and
perceived value in the system often adds to the frustration o f nurses w ho w ant to offer
w om an-centered care, but feel overw helm ed by the obstacles. This frustration is
verbalized by obstetrical nurse Susan D iam ond (1996) in her autobiography, H ard L abor:
All the old conditioning, the w ay I was brought up— to respect the doctor,
to follow the rules— conflicts w ith what m y experience and com m onsense
tell me. I ’m 'only the nurse.' I don't know as much as the doctor does..It is
particularly difficult for m e to acknow ledge the truth about such attitudes;
to recognize that I am qualified and experienced in my w ork; that
flexibility is a significant attribute to bring to m y work; and that m y role as
the patient’s advocate is a legitim ate one. I have to fight m y ow n
hesitancy, m y insecurity about challenging authority, and w ork diligently
to assert m y self with doctors w ho may not be responding effectively to a
patient’s needs. W hen I am able to overcom e m y fears and frustration and
dem onstrate an alternative m ethod o f pushing, for instance, w ithout
insulting or dem eaning the physician, it feels wonderful. U nfortunately,
the longer I w orked, the harder it was to generate the energy necessary for
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such assertiveness...T he grueling hours, the intensity o f the w ork itself,
and the enorm ous number and variety o f m edical personnel I had to w ork
with sapped m y energy, (pp. 322-323)
External Forces that Impacted M aternity N ursing
The w om an’s health movement.
The resurgence o f feminism beginning in the 1960s and the w om en and
consum er’s health m ovem ents contributed to changing the philosophy o f care in
obstetrical areas to prom ote partnership with the w om an/client (A m ey, 1982). T he
nursing profession did not collectively em brace the fem inist health m ovem ent that
sparked the initiative for change. H ow ever, individual nurses were leaders in the self-help
m ovem ent and in organizations, such as ICEA, that sought autonom y o f w om en to
becom e self-educated and empowered to choose am ong alternative birth options
(C assidy-B rinn et al., 1984; McKay, 1982). N urses began to write about and
acknow ledge issues related to nursing practice, gender, feminism and w om en’s health
care (R eavi11, 1976; Sandelowski, 1981; 1984).
The fem inist health movement infiltrated traditional maternity nursing care
through the guise o f the family-centered m aternity care movement (FCM C). The FCM C
m ovem ent, spearheaded by ICEA, touched the hum anistic nature o f m aternity nurses who
believed w om en should have family support available throughout birth (H aire, 1975;
M cKay, 1982; Sonstegard & Egan, 1976). FCM C encom passes values consistent w ith the
w om en’s health m ovem ent. These values include beliefs that the w om an’s individuality
and sense o f autonom y should be respected as she experiences birth as a norm al, yet
m ajor life event. A m ajor principle o f this model depends on the staff providing
com prehensive childbirth education and unbiased inform ed consent during childbirth.
W ithin a m odel o f FC M C a woman identifies her fam ily who is treated as a unit and not
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separated during the birth process. Attitudinal changes among caregivers in hospital
settings is recognized as the prim ary pre-requisite to practicing FCM C. Educational
strategies were planned to reorient all caregivers to practices that included the family unit
(M cK ay & Phillips; 1984; Phillips, 1994).
As a consum er-driven m ovem ent the nursing and m edical professions
acknow ledged the benefits o f FCM C and studied how to im plem ent the philosophy.
N A A C O G supported changes in the hospital routines that prom oted fam ily-centered
childbirth policies and participated w ith obstetricians, pediatricians, and nurse-m idwives
in w riting the 1978 Interprofessional Joint Position Statement o n FCM C. This position
statem ent outlined standards o f care recom m ended for establishing hospital protocols
conducive to the “ provision o f m atem ity/new bom care which fosters family unity while
m aintaining physical safety” (M cKay & Phillips, 1984, p. 235).
Plans for changing hospital settings to offer FCM C w ere often initiated and
“officially” approved through collaborative obstetrical com m ittees m ade up o f hospital
adm inistration, obstetricians, pediatricians, and nurses. However, nursing m anagers and
clinical nurse specialists were often the leaders in im plem enting the specific unit
strategies (Paukert, 1979; Sonstegard & Egan, 1976; Vestal, 1982; Vezeau & H allsten.
1987). M aternity nurses worked w ithin the system to change hospital policies regarding
father and sibling visitation. Redesign o f rooms included planning suites w here labor,
delivery, and recovery occurred in the same room (LD R ) and single room m aternity care,
w hich also included postpartal care in the same room (LDRP). H ospitals that used a LDR
design often converted the postpartum and newborn nursery to a m other/baby unit in
w hich the nurse cared for the postpartal woman and the newborn as a pair, com m only
called couplet care (Phillips, 1994). Statistical data w ere com piled by advanced practice
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nurses to validate the “safety” o f changes and fam ily satisfaction (Cottrell & G rubbs.
1994; Faxei, 1980; Sonstegard & Egan, 1976).
Implem enting FCM C necessitated changes in m odels o f nursing care and work
assignm ent o f nurses. Nurses could no longer claim expertise in only one area o f the
childbearing process, such as labor and delivery o r postpartal care. Caring for the family
as a unit required nursing service departm ents to reeducate and cross-train nurses to leam
skills necessary to caring for the wom an and fetus/new bom and fam ily throughout the
birth as one client (Harvey, 1982; Steensma. 1993; V ezeau & H allsten, 1987). N ursing
m anagers and staff who supported the changes rep o rted the period o f transition as
stressful due to resistance and turnover by nurse peers, doubt and criticism from hospital
adm inistration and some physicians, and general feelings o f anxiety as jo b expectations
changed. Yet, nurses committed to FCM C reported th a t the changes that benefited
w om en and babies were worth the effort (Stolte, M yers, & O w en, 1994; W atters &
K ristiansen. 1995).
A lthough the FCM C thrust o f the 1970s-1980s improved m aternity services, the
m ovem ent did not result in promoting the norm alcy o f birth o r in supporting w om en in
alternatives to technological care (Ruzek, 1978; W agner, 1994; Y oung, 1982). Recently,
nurses questioned the success o f the FCM C m ovem ent to provide w om en a w ellness and
em pow ering model o f childbirth. The possibility for autonom y and a “choice o f
alternatives” in childbirth are often invisible in the im plem entation o f FCMC.
A utobiographical accounts o f nurses’ experiences in practice situations expose
oppressive routine medical intervention and a perceived lack o f nursing action to change
practices in labor care (Diamond, 1996; Dwinell. 1992; Perez, 1989).
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N urse entrepreneur M arianne O lson (1993; 1998; 1999) created a business. The
C hildbearing Years, to address the need for continued reform in childbirth health care
services in the 1990s. O lson (1998) provides education and consultation serv ices to
im plore m aternity personnel to question their em phasis on rituals o f care based on w hat
she calls “TH E STA N D A R D ... “Because w e’ve alw ays done it that way here!” O lson
advocates changes in the health care atm osphere that generates positive relationships with
fam ilies. She attacks the hierarchical nature o f hospitals and m otivates the hospital health
care team to establish a professional model o f collaboration that centers on the
w om an/fam ily’s interests. O lson’s (1999) research w ith consum ers illum inates the -
continual em phasis on hospital and m edical control o f childbirth options. She collected
data from 1,500 consumers o f m aternity services during postpartal family forum s from
the hospitals in which she provided consultation services. Forty-three percent (643 o f the
1.500) o f the w om en reported being induced for labor; ninety-four percent (1,410 o f the
1.500) reported not being offered choices during labor; ninety-four percent (1,440 o f the
1.500) had continuous electronic fetal m onitoring during labor and one-hundred percent
o f the w om en who were monitored stated they w ere not given an option o f interm ittent
m onitoring.
C hildbirth nurse educators and m idwives question the em pow ering and
em ancipatory potential o f childbirth education in the 1990s that seem s to only prepare
w om en in w hat they should expect in technocratic birth. Independent childbirth educators
w ho provide advocacy and educate for informed consent are central to the w o m an ’s
health m ovem ent and FCM C. Over time, as childbirth educators becam e em ployed by
hospital system s, they experienced a role conflict regarding to w hom they w ere m ost
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responsible - the wom an, physician o r institution’s interests (A rm strong & Feldman.
1990; N ichols, 1993; Shearer, 1984; Zw elling, 1996).
N urses w ho stepped outside the m ainstream model o f hospital-based m aternity
nursing to w ork as monitrices acknowledge the need for m ore autonom ous and
individualized approaches to caring for wom en during labor (H odnett & O sbom , 1989;
H om m el. 1969; Peddicord, Curran, & M onshow er, 1984; Perez, 1984). N urses who
practice as professional labor assistants or m onitrices act as private duty nurses employed
directly by the w oman/family. M onitrices believe their position outside the system
prom otes their ability to educate, offer inform ed consent and support w om en in birth
alternatives. The nurse working as a m onitrice in labor com bines her nursing assessment
skills and emotional, com fort skills to supporting and advocating for w o m an ’s personal
birth goals throughout the labor process, w hile also m onitoring for physical safety.
C ontinuity o f labor and birth care is ensured by elim inating nurse assignm ents based on a
shift system (Perez & Snedeker, 1990).
As the professional organization. A W H O N N (CIM S, 1996) took actions that
indicated concern for improving the current health care system and the nursing care
necessary to supporting a wellness model o f birth. AW HONN participated w ith CIMS
(1996) in the developm ent o f its recom m endations, the Ten Steps o f the M other-Friendlv
C hildbirth Initiative. The recommendations that identify strategies to prom ote wellness
m odels o f care in hospital settings have direct im plications for nursing. F o r exam ple, the
initiative calls for educating staff in non-drug m ethods o f pain relief and prom oting the
use o f analgesic or anesthetic drugs not specifically required to correct a com plication.
The need for such a step to educate staff indicated the need to reorient nurses, as the
prim ary caregivers during labor, to the art and science o f attending to w o m en ’s comfort
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needs outside a medical m odel. A shift in AW HONN (1998; 1999) educational topics
toward supporting norm alcy in birth increased. For the past two years, the annual
A W HONN conventions have offered continuing education sessions aim ed at teaching
nursing intervention to support norm alcy in birth, confronting issues related to the need
for doula caregivers and recognizing problem atic issues w ith the technocratic model o f
birth (AW HONN, 1998; 1999).
A W H O N N ’s research endeavors also dem onstrate a com m itm ent to supporting
the normalcy o f birth. A W HO N N spearheads research utilization projects, such as the
project to change protocols for second stage labor where closed glottis, coached pushing
in a lithotomy position w as the norm. Protocols are established and researched to
elim inate closed glottis pushing and replace these routines w ith practices to support
spontaneous pushing (N iesen & Quirk, 1997; Peterson & Besuner, 1997).
The Technology Revolution.
As nurses participated in setting up FCM C policies in the 1980s, technology
continued to dram atically change the options for childbirth and the w ork o f the nurse.
Physicians delegated to nursing the use o f obstetrical technology, such as m atem al/fetal
electronic m onitoring, thus transferring m edical practices to the work o f nursing
(Sandelowski, 1996a). N urses’ knowledge concerning the nature o f birth w as reinvented
through technologic interpretations, w hich in turn reinvented and changed the nurses’
role in labor care (Sandelowski, 1997). As nurses struggle w ith changes in the delivery o f
humanistic care, technological-focused assessm ent replaces touch and prom otes the m yth
that care is im proved sim ply because technology is available (Hawthorne & Yurkovich,
1995; Phillips, 1988; Sandelow ski, 1989; W eaver, 1990). The legal clim ate that affects
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the health care system requires nurses to spend m ore tim e interpreting and docum enting
technological data (R ostant & C ady, 1999).
The increasing cesearean section births, pitocin inductions and routine use o f
epidural anesthesia causes nurses to focus on m onitoring for potential com plications from
these procedures, w hile sometimes neglecting the psychosocial needs o f the individual
woman. This is m ost evident in research that indicates women and their partners place
value upon interpersonal and supportive nursing care during labor, yet nursing tim e and
expertise is often centered upon technical care (Bryanton, Fraser-Davey, & Sullivan,
1994; M ackey & Stephans, 1994; M cN iven, H odnett, & O 'Brian-Pallas, 1992; O lson.
1999). Unfortunately, financial investm ents in obstetrical care cen ter on expanding
technology and boosting commercial profits, as opposed to developing models o f care
m ore conducive to one-on-one nursing support (W agner, 1994).
The M anaged Care Environment.
Shortened m aternity stays o f 24 to 48 hours after birth causes maternity nurses
stress as they cope w ith increasing dem ands o f high technology, FC M C and cross-
training to work across labor, new born, and postpartum settings (Stolte et al., 1994).
V alidating readiness for discharge and discharge teaching falls on the nurses. N urses
realize that short stays are inadequate to educate and support m any new m others’
recovery and adjustm ent to parenting. M others w ith social or physical com plications
require m ore intense care. The nursing response to shortened stays includes developing
an array o f alternatives to provide nurse-m anaged follow-up care b y telephone, hom e
visits, or postpartal clinics (Keppler, 1995; W illiam s & Cooper, 1992). Nurse researchers
validate postpartal needs o f women and babies and evaluate the client outcomes and cost-
effectiveness o f such program s (B rooten et al., 1996; York et al., 1997). These actions
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represent the resourcefulness o f m aternity nurses as they continue to respond to
bureaucratic stresses imposed on their practices and the health care experiences o f
w om en.
D iscourses Reflected in M aternity Nursing Textbooks
I review ed a representative set o f m aternity nursing texts looking for general
trends in published discourse. The texts w ere intended for use in the academic education
o f novice nursing students or for continuing education for nurses in practice (Ladew ig,
London, & Olds, 1998; Lowdermilk, Perry, & Bobak, 1997; N ichols & Zw elling, 1997;
Reeder, M artin, & Koniak-Griffin, 1997; Sim pson & Creehan, 1996). The review was
conducted as a crude overview o f topics and chapters, with no specific m ethodology for
text analysis. I recognize that I reviewed these texts as a fem inist maternity nurse
educator and filtered what I read through m y personal “text.”
The m aternity nursing texts reflect fram ew orks consistent w ith academ ic nursing
education and standards set by the A m erican N urses’ A ssociation and A W H O N N . The
nursing process, critical-thinking and clinical pathw ays are presented as a basis for
clinical problem -solving and intervention. Each text has at least one chapter th at focuses
on ethical-legal, inform ed consent, research, and public policy issues in m aternity care.
M ultiple roles o f the professional nurse in m aternity care are explored based upon
practice areas, such as the hospital nurse, hom e care nurse, o r fam ily planning nurse.
Specialized education or advanced practice licensure o f the m aternity nurse is also
differentiated, such as the m asters’ prepared clinical nurse specialist, nurse practitioner,
or the certified nurse midwife and certified lactation specialist.
Yet, each te x t’s primary function is to teach nurses clinical maternity care around
the technocratic m odel o f care characteristic o f current practice trends. The m aternity
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nurse is presented as the appropriate caregiver for w om en and babies in three levels o f
care, prim ary (w ellness, prevention), secondary (acute care for com m only recurring
problems), and tertiary (high risk or chronic care). Therefore, clinical content in texts
contains the entire spectrum o f childbirth possibilities -- educating nurses for whatever
level o f care is required to care for w om en and babies. Each text I review ed presents
normal pregnancy and childbearing focusing on preventive health care, assessm ent and
teaching b y the nurse to provide supportive pregnancy, labor and postpartum /new born
care in a scenario o f m inim al intervention. Holistic care is m inim ally m entioned and
usually in relation to pain management, such as therapeutic touch and acupressure. Each
text presents betw een two and four chapters on normal birth and new born care. The
rem aining chapters explore the intricate details o f antenatal diagnostic tests, continuous
electronic fetal m onitoring, anesthesia, and care in high-risk conditions o f pregnancy,
pitocin induction, operative delivery, and emergency care in life-threatening situations for
m other/baby.
The fam ily is consistently presented as the prim ary focus o f care in m aternity
nursing practice. O nly one text was reviewed that indicated a balance o f the benefits o f
the FCMC m ovem ent w ith the controversy over excessive medical intervention, but this
is limited to one section o f an introductory chapter (N ichols & Zw elling, 1997). The
general discourse in the texts reflected FCM C as a reform m ovem ent that improved the
system o f care delivered to families. There w as no association made w ith the w om en’s
health m ovem ent and the reform for FCM C, nor any general mention o f fem inist health
care initiatives. Obstetrical technology is presented positively, as a form o f expert care
requiring nursing know ledge to use and interpret the results to improve health care for
women. A fem inist or postm odern perspective is generally absent from all texts, even
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when controversial issues are presented such as motherhood and w ork issues, day care
and support for breastfeeding. Issues in maternity care sometimes reflect the im pact o f
poverty and m inority status o f women, but the texts do not critique the issues w ithin a
critical or em ancipatory stance to advocate action by m aternity nurses to change the
health care environm ent. The one exception is violence against w om en, where the role o f
nurses to detect and advocate for women is strongly addressed.
Educational Theory and Woman-Centered M aternity N ursing Education
Knowledge to practice maternity nursing encom passes a diversity o f discourses
and perspectives. Through exposure to juxtaposed discourses, nurses in education and
practice settings m ay com e to recognize and critique the discourses that impact th eir
nursing care experiences w ith childbearing women. Such critical aw areness is necessary
for the nurse to com e to know how the claims to truth embedded in discourses affect
w om en’s experiences in childbearing and nursing practices. As all disciplines question
the project o f m odernity, nursing education also looks critically at how dom inant
discourses shape nursing practice and the health care o f people.
Centering birth as a medical event, defined by a patriarchal health care system ,
inherently values nursing practices that support medically-oriented discourses such as
labor induction and episiotom ies, while potentially devaluing interventions to prevent
such medical interventions. Valuing only discourses supporting technocratic birth limits
knowledge o f alternative choices in care. Other possibilities for nursing care and
childbirth options are not imagined or made possible w hen discourses are limited. A
postm odern, w om an-centered m aternity nursing education offers a site where nursing
education can decenter dom inant medically-focused discourse and open nursing students
to diverse discourses. W oman-centered perspectives intend to expose health care
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practices that are insensitive to w om en’s experiences and seek to control w om en’s bodies
for the convenience o f caregivers rather than based on the w om en’s know ledge and
choice o f alternatives. W om an-centered nursing education w ould b e aim ed at raising
caregivers’ consciousness to the disciplinary pow er o f dom inant discourse, exposing
injustices and thus offering spaces to transform the status quo. W om an-centered
m aternity nurses can potentially open nurses to imagine another w ay to care for w om en.
It has been theorized that em ancipatory approaches in m aternity nursing care can act as
nursing praxis to enable w om en/clients to gain control over the o ptions for safe birth
(Cheek & Rudge, 1994a; H enderson, 1997; Varcoe, 1997). Learning em ancipatory-
approaches requires a transform ing curriculum that challenges taken-for-granted
perspectives and offers the potential to awaken the nurse-leam er to new possibilities for
providing care.
Postm odern curriculum theorist W illiam Doll (1993) believes a transform ing
curriculum is generated through m ultidirectionality, m ultiperspectives and personal
m eanings that sufficiently bother, confuse, and unsettle the student in a generative
manner. In a transform ing curriculum students experience the status quo as they confront
new perspectives and generate their ow n viewpoint through their relationship to the
curriculum and their experiences. Transform ation o f thinking and being takes on personal
meaning through the student/nurses’ personal experiences.
Educational theories that support woman-centered m aternity nursing education in
this context are found w ithin the w ork o f the following three curriculum theorists: Patti
Lather, M axine G reene and W illiam Pinar. A transforming curriculum foundational to
w om an-centered m aternity nursing is theorized looking through ideology o f postm odern
feminist pedagogy as theorized by Patti Lather. The possibilities o f an em ancipatory
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curriculum that sparks em pathy, imagination and freedom w as theorized through Maxine
G reene’s liberatory philosophy o f education. A utobiography as the personal connection
required to experience education as personal transform ation w as characterized through
W illiam P in ar’s work on autobiography as a educational strategy and reflection o f being.
Patti Lather
L ather’s (1986a, 1986b, 1987, 1991, 1992) curriculum theorizing centers around
her quest for research and teaching methods that continue to challenge liberatory
educational theory. Lather turns to critical discourses o f fem inism , neo-M arxism s and the
postmodern to study how these contribute to em ancipatory scholarship and the search for
praxis through research and education. Lather deconstructs critical-fem inism and
intersects the m etanarratives o f liberatory theory with postm odern theory. Lather's goal is
to find ways to turn critical thought into emancipatory action. Through her ow n research.
Lather theorizes about alternative ways o f conducting educational research and practicing
em pow ering pedagogy som etim es characterized by student resistance.
Lather (1991) offers discourse on the possibilities and lim itations o f liberatory
theory in education by exploring the intersection o f postm odernism to the fem inist and
neo-M arxist discourses o f em ancipation. Lather (1991) presents a poststructuralist view
o f M arxism, described as a "m ovem ent o f controlling, labeling, and
classifying...Transform ing difference into dichotomous oppositions, it reduces
m ultiplicities and plurality into a single-oppositional norm " (p. 24). Lather believes
postm odernism gives space to question the m anner in w hich M arxism represents the
"truth" concerning a totalizing, universal emancipation. A post-M arxist space debunks
the binary o f "liberation versus oppression" and decenters M arxist discourse as being
only one am ong many possibilities for em ancipatory discourse. Lather offers
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poststructuralist analysis o f pow er and know ledge to m ulti-center opposition discourse,
m aking the discourse more responsive to contem porary problem s. Likew ise, Lather
believes postm odernism re-situates fem inism by pointing out the universalizing nature o f
fem inist theory that is intended to represent all women, but left out the poor, working
class, lesbians, women o f color, fat and old er women. Postm odernism m oves essentialist
M arxist discourse on gender toward accepting the notion o f no absolute, static self. In
turn, the political practice o f feminism m oves postm odernism in new directions.
Through her research efforts, L ather explains sites w here postm odernism and
em ancipatory education intersect. Lather believes postm odernism opens questions to how
liberatory pedagogy may actually perpetuate dominance through critical theory.
A ccording to Lather, dominance occurs w hen the conscious individual acts as a master
attem pting to speak for w hat others want o r need. Lather (1991) critiques how the
authoritative nature o f critical pedagogy assum es the pow er o f disclosing w hat discourse
is facilitated, marginalized and what interests were served. Lather raises the issue o f how
em ancipatory pedagogy m ay serve to perpetuate dominance. Lather believes a
postm odern, liberatory teacher and curriculum needs to be sensitive to students
experiencing space for becoming, w ithout feeling that a certain ideology is im posed upon
them. This necessitates an emancipatory curriculum eliciting personal involvem ent with
the course in an atm osphere o f freedom. A "relation between the know er and the known"
m ust be nurtured (Lather, 1991, p. 143).
The teacher's identity determined by subjectivity, language, and pow er are
recognized as sites for deconstruction. L ather (1991) asks how teachers could be
positioned as "less masters o f truth and ju stice and more creators o f space..?" (p. 143).
D econstruction o f authority in pedagogy points to the need for teachers to refrain from
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defining practices or offering only one interpretation. Rather the classroom and texts
should provide space for difference and conflicting views. Lather calls for m ultiple
readings o f texts that demonstrated unlim ited meanings depending on the social situation
o f the person reading the text. The text/discourse invites the student to enter and explore
the relation between the self and the m eanings derived.
Lather believes teachers and students should analyze discourses to recognize how
discourses serve to dom inate and inscribe one's identity. The relation betw een the know er
and w hat is known through discourse is at th e center o f liberatory pedagogy. Lather calls
for classroom s where students were confronted with values and m eanings, not
authoritative knowledge. Lather (1991) suggests the object o f em ancipatory education is
the aw areness o f "power-saturated d iscourses that m onitor and norm alize o u r sense o f
who w e are and what is possible" (p. 142). T h e choice o f discourse given space can be a
potential site o f dominance, should the faculty give authority status to one source and
force the know er to accept that discourse a s "truth" to be applied to subsequent course
activities. Lather theorizes that the project o f emancipation is dependent on raising
consciousness to the pow er o f ideology o f discourse, as the student com es to know her o r
his own com plicity with dominant discourse. As Lather points out, students m ust com e to
understand their own relationship with dom inant discourse, how it sets boundaries and
limits lives. Lather believes in juxtaposing discourses o f dominant, diverse, and
m arginalized voices in order to develop the student's awareness o f m ultiple perspectives.
To debunk the authority o f one discourse o v e r another, readings from various discourses
should be used. Both/and perspectives o ffered in postm odern feminist pedagogy w ould
open all discourses to scrutiny.
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M axine G reene
M axine Greene's (1988, 1995a) educational theory represents w hat she calls her
"quest" (1988, p. xi) - her "life project," (1995a, p. I) to connect the public sphere o f
education w ith the personal lives o f individuals for the possibility o f a m ore hum ane
society. In essays and books written over the past tw enty years, G reene theorizes for hope
in im proving the educational experience through changing the philosophy o f education
em bedded in the American school system. Greene challenges teachers to no longer
m erely reproduce the detached, individualist, m onolithic system o f education. G reene's
theorizing looks beyond the status quo to find renew ed possibilities in teaching, and thus
renew ed possibilities for student experiences in education and life.
G reene (1995a) acknowledges that one purpose o f schools is to prepare young
people w ith skills necessary to work in a post-industrial, technological society. As
disciplines teach technological skills, there is a quest for certainty, the m anageable, the
predictable, the measurable. The student is considered a "human resource" to be m olded
for the m arketplace. Greene (1995a) believes to prepare students for life in a
technological society requires engagement with an active learner - a contextual being that
defies prediction, m anagem ent and measurement. To Greene, an aw akened, active learner
is one w ho can grow as a person and pursue m eaning in her/his work and life story and
com e to know how to go about learning. Greene (1995a) challenges teachers to educate
for the "grow th o f persons, to become different, to find their voices, and to play
participatory and articulate parts in a com m unity in the m aking" (p. 132). It is in the
pursuit o f this active, conscious learner that G reene’s educational theorizing centers.
G reene's (1978) work calls attention to the m ultiple realities, personal histories,
and lived lives o f teachers and students, w hat she called "landscapes" (p. 2) or vantage
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points for learning. G reene (1995b) advocates that teachers as well as students reflect on
their life histories. T his is the rich, perceptual background for learning. Only through self
reflection in a situated life can critical and thoughtful learning occur. A s Greene (1978)
states, "O ur being there in person" (p. 85) opens new possibilities for learning. G reene
believes "being there" in critical reflection enables students to becom e conscious o f the
ways the world is encountered. In G reene's (1988) w ords, "C onsciousness..involves the
capacity to pose questions to the w orld, to reflect on w hat is presented in experience" (pp.
20-21). This conscious connection to the w orld is necessary to aw aken students to the
conditions o f others and deficiencies in society.
G reene believes engagem ent and dialogue w ith others in education opens
aw areness o f m ultiple perspectives inherent in a pluralist society. C ritical aw areness
rescues the student from indifference and inertia and focuses upon the possibilities o f
what ought-to-be. Teaching for critical consciousness opens possibilities for praxis,
where intentional actions can transform situations to overcom e oppression and
dom ination and provide possibilities for freedom. This praxis requires im agination for a
better w orld, naming alternatives and seeking openings to discover new possibilities
(Greene. 1978; 1988). Critical aw areness is a w ay o f teaching for ethical concern and
included attending "critically and sensitively to context" (Greene, 1990, p. 72). O f special
concern to Greene (1993a, 1993b) is the context o f individuals' lives m arginalized as
"other" by gender, race, ethnicity, class, o r sexual preference. A w areness o f a
m ulticultural, pluralist society acknow ledges the need for teaching for a sense o f
com m unity. Greene calls for classroom s w here inclusion and com m unity are possible,
without conform ity.
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To create such possibilities in schools, Greene (1995a) proposes "transform ed
pedagogies" that relate existing conditions to som ething that "goes beyond a present
situation" (p. 51). Greene believes there are ways to teach that connect education to the
possibility o f wide-awakeness, authenticity, and moral sensitivity. Greene proposes a
conscious, self-aware teacher as the starting point. Greene believes teachers m ust actively
choose to develop a humane and liberating pedagogy. Teachers m ust act to recapture lost
spontaneity, becom e aware o f their ow n backgrounds and bring unresolved dialectics o f
lived situations into the classroom. Teachers' voices m ust carry passion and outrage over
injustices and arouse possibilities for change. G reene (1978, 1988, 1995a) calls for
teachers to exhibit passion, care, indignation, m oral sensitivity, and authenticity. Such
characteristics im ply that the faculty present them selves with a conscious point o f view
that will be evident in teaching and their w ay o f being w ith others.
Greene (1994; 1997) calls for lived situations, reflective encounters, and class
dialogues that opened the notion o f m ultiple realities and meanings. Greene (1995a)
advocates the need for releasing the im agination to enter another’s world and see the other
through a new vantage point. A ccording to G reene (1995a), im agination is w hat m akes
"em pathy possible...give credence to alternative realities...break w ith the taken-for-
granted" (p. 3). G reene believes routes to release the imagination o f students are achieved
through engagem ent in the arts created by w riters, painters, sculptors, filmmakers,
choreographers, and composers. Such reflective encounters apply cognitive and affective
knowing, resulting in multiple interpretations and meaning. H um an consciousness is
connected to active engagement w ith the arts. Greene (1993b) argues that the arts "can
aw aken us to alternative possibilities o f existing, o f being human, o f relating to others, o f
being other..." (p. 214). M etaphors in poem s, novels, and other literature are seen as a
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m eans o f grasping what is out o f reach. In the m edium s o f art. the images o f good are
contrasted w ith horrors (Greene, 1995b). G reene theorizes that through the arts the
experiences and voices o f others are made clearer and learners becom e more conscious o f
daily routines and habits. Exploration through the arts creates possibilities for learning
and finding connection and com m unity, but not com pleteness. As Greene (1990) stated, it
is preferable that the student, as an active, transform ative being, experience
"incom pleteness and unsatisfied indignation and vision o f possibility" (p. 75).
Greene <1978; 1988) offers hope that em ancipatory education can take p lace as a
search for freedom. Critical reflection on lived situations opens spaces for hum an -
consciousness to emerge. Critical consciousness o f the contradictions in the m odem
w orld starts the student on the search for a personal sense o f “w hat ought-to-be.” G reene
(1988) contends freely choosing the "ought" o r "should" occurs w hen the person takes the
situation personally, recognizes obstructions to freedom , and im agines a better state.
Engagem ent in meaningful dialogue with others connects situations to a shared w orld and
m akes space for awareness o f diverse possibilities. Greene (1994) believes the
postm odern sense o f se lf is capable o f changing as new inform ation is interpreted.
W illiam Pinar
W illiam Pinar’s (1994) theorizing acknow ledges the focal point o f curriculum to
be the individual's education as experienced w ithin the person’s life history. Pinar
believes that education occurs through the self-transform ative nature o f autobiographic
work. Pinar's thrust for autobiographical curriculum study corresponds with his d rive to
sustain a "reconceptualization" o f the curriculum field. This paradigm shift in the field o f
curriculum in the 1970s was a response o f curriculum scholars to the technical m ode o f
"curriculum developm ent" that was obsessed w ith control, prediction, and detachm ent o f
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the person founded in Tylerian rationale (Tyler, 1949). Pinar (1994) speaks o f this period
in the following, "Entering the openings created by the work o f Jam es B. M acdonald,
D w ayne Huebner, Paul Klohr, and M axine Greene, w e insisted on doing business very
differently" (p. 1). Pinar’s scholarly w ork during this period is his autobiography o f living
through the paradigm war.
The European traditions w hich provided insight for the reconceptualization o f
curriculum included M arxism , existentialism , phenom enology, and psychoanalysis.
These traditions held com m on "dissim ilarity to the behaviorism and em piricism
characteristic o f A m erican social science and educational research" (Pinar, 1994, p. 68).
Pinar’s theorizing to center the study o f curriculum as autobiographical is intrinsically
linked to the ideals o f the reconceptualist curriculum scholars who supported a shift aw ay
from conceptual em pirical thinking that characterized the traditional curriculum field.
Pinar describes how he "stumbled" onto autobiography as a result o f his experience
teaching high school students in a system o f education that he perceived to be antithetical
to learning. Pinar presum ed any learning that occurred originated w ithin the lives o f the
students and teacher rather than from an external subject matter, know n as "curriculum ."
P inar’s (1975) ow n reconceptualist work is grounded in his attem pt to find a
deeper understanding o f the individual’s lived experience o f curriculum . Pinar believes
curriculum research should return to the experience o f the individual through a process he
termed “currere.” Pinar uses an etym ological derivative o f the w ord curriculum ,
“currere.” the Latin w ord “to run,” as to “ run a course.” Pinar theorizes that currere w as
"not the course to be run, or the artifacts em ployed in the running o f the course” but
rather “the running o f the course” (P inar & Grum et, 1976, p. 45). P in ar believes the heart
o f understanding curriculum is not in the artifacts o f curriulum (content, teaching plans,
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books), but rather w ithin the individual and her o r his world in relationship to the
experience o f schooling (Grum et, 1992). As explained by Sum ara (1996),
C urrere explicitly acknowledges that there can be no fixed and clearly

defined boundary between schooling and other lived experiences; events
o f schooling becom e inextricable from the path o f life. O f course, this is
not a pre-determ ined path; the path o f life, as Buddhist philosophers have
told us, is a path laid down w hile walking. This path depends upon
everything, and everything depends upon the path. (p. 174)
Pinar (1994) sees the potential o f personal m ovement through the process o f
autobiographic w ork, believing the past leads the future. As Pinar (1994) states, "The past
is present. To the extent that one is unconscious o f the past one is caught in it. O ne is
arrested, tem porally and developm entally" (p. 57). Pinar proposes that the way to begin
m ovem ent w as by the person w riting about his o r her life, personal experiences, and/or
educational experiences. The written page brought the past to the present and looked to
the future to see a new view. Analysis o f this written page o f one's life opened up
possibilities for interpretation. Interpretation was m ade possible b y detaching from the
experience and loosening and breaking apart. Pinar (1994) explained that in, "bracketing
w hat is, what w as, w hat can be, one is loosened from it, potentially m ore free o f it, hence
m ore free to freely choose the present, and future" (p. 26). A utobiography becom es a
form o f consciousness that frees for movement toward an authentic self.
In essays w ritten by Pinar (1994), Grumet (1981), and Pinar & Grum et (1981),
autobiographical w ork is defended surrounding the criticism s o f focusing on the
individual and ignoring political and cultural schooling issues. Pinar (1994) w rites to the
necessity o f autobiography in the "gradation o f liberation" (p. 102). He believes that
invisible autobiographical work transformed the individual, which in turn is political
work that can potentially liberate society or groups. Pinar extends this notion o f inw ard
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transformation to the curriculum field, encouraging m em bers o f the field to look inwardly
for rekindling education, rather than depending on the external notion o f curriculum
(texts, standard lesson plans, policy). As stated in Pinar, Reynolds, Slattery & Taubman
(1995) "the point o f curriculum is to goad us into caring for ourselves and our fellow
human beings, to help us think and act w ith intelligence, sensitivity, and courage in both
the public sphere-as citizens aspiring to establish a dem ocratic society-and in the private
sphere, as individuals com m itted to other individuals" (p. 848).
A nother aspect o f Pinar’s (1994) theorizing looks at gender identity and
patriarchal influences on the biography. U sing a Freudian, psychoanalytic perspective,
Pinar theorizes about m ale-m ale relationships in W estern, patriarchal culture. Pinar
hypothesizes the role o f repression and resistance in form ing male-male relationships
among heterosexual and homosexual men. From this analysis, Pinar demonstrates how
the classroom is also patriarchal, with the traditional curriculum representing the
authority o f the father.
Educational Theory and Implications for this Study:
I explain my personal work toward creating a w om an-centered m aternity nursing
course through the educational theory o f Lather (1991), G reene (1988, 1995a), and Pinar
(1994). I filter the teaching o f core m aternity nursing through postm odem -fem inist theory
full o f m ultiple discourses and tensions (Lather 1991). D om inant discourses related to the
nursing and medical care o f childbearing w om en are learned w hile being deconstructed
w ithin the context o f a woman-centered philosophy. B ecause I choose to teach this way,
the undergraduate students are compelled to confront issues that challenge their taken-
for-granted values and beliefs about nursing, nursing education, women, childbirth, and
the culture o f medicalized health care. M axine Greene’s (1988, 1990, 1995a) theory
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supports m y b e lie f that a w om an-centered m aternity course should open the student to
plurality o f perspectives w here openness to others will occur, w here they will see the
injustices bestow ed upon w om en and find em pathy for others. I use m edium s for teaching
that I believe touch students through the affective domain and tap into th e ir im agination
to answer the question, “how can m aternity services be im proved to benefit w om en?”
This liberatory education is imposed on students in the classroom , but what
aspects are accepted, rejected, o r som ew hat assimilated into their personal beliefs and
practices is dependent on the individual student. The path chosen occurs through the
students’ connection to their learning o f m aternity nursing, their clinical experiences w ith
wom en, and their personal lives — w hich becom es their life history (Pinar, 1994). As a
nurse educator this research represents m y desire to understand how the theoretical tenets
used in teaching w om an-centered m aternity nursing influence nursing praxis and affect
lives. I want to understand how fem inist-postm odern theory and em ancipatory themes
m ay be integrated into nurses’ clinical practices or rejected by nurses. T he personal
m eaning o f a w om an-centered m aternity nursing education for nurses after they enter
m aternity practice is at the heart o f this research study. Through phenom enology
research, the personal m eanings o f the nurses’ education can be revealed as they share
their own life history o f being a student in the course and a current nurse in m aternity
care settings. This research study w ill attem pt to dissolve the boundaries betw een
schooling and life by discovering and understanding nurses’ current practices (Pinar,
1994; Sumara, 1996).
Summ ary
I proposed a transform ing, w om en-centered maternity nursing education as a w ay
to influence the individual practices o f m aternity nurses and offer hope to im prove health
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care delivery for childbearing w om en. I located curriculum theory through the w ork o f
Patti Lather. M axine Greene, and W illiam Pinar that I believe is foundational to the
creation o f w om en-centered m aternity nursing education. I proposed this research study
as a w ay to understand how theoretical tenets used to teach w om an-centered m aternity
nursing may affect nurses’ practices and w om en’s experiences.
N ursing R esearch Context
A few studies w ere conducted that reflect research-based evaluation o f fem inist
and emancipatory curricula in nursing education (Beck, 1995; Boughn, 1991; B oughn &
W ang, 1994). For the purpose o f this study, I focused on the research studies that
exam ined the experiences o f nursing students and/or outcomes on nursing practices as a
result o f nursing educational experiences influenced by feminist pedagogy. In these
studies nursing teachers described their experiences using tenets o f fem inist pedagogy
and em ancipatory education that connect the nursing student to personal and professional
self-consciousness. T hese studies supported the potential o f fem inist pedagogy to change
nursing student’s curricular experiences and perspectives. A presentation o f this research
literature follows.
Nurse educator Susan B oughn conducted both a qualitative and quantitative study
to evaluate a feminist nursing course she added to the curriculum at Trenton State
U niversity in Trenton, N ew Jersey. The nursing course entitled, “W om en and Health:
Power, Politics, and C hange,” w as offered as an elective in the baccalaureate nursing
program and was opened to nursing and non-nursing majors (B oughn, 1991). A ccording
to Boughn. the course used a fem inist perspective to examine w o m en ’s concerns as
consum ers and providers and to prepare nursing students to function as effective
advocates for the fem ale health care consumer. T he issues included psycho-sociological
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concerns that affect the health and lives o f w om en in society, such as sexual assault,
battering, incest, and reproductive freedom. Boughn and W ang (1994) described the
course in the following statements:
Course content is based on the fem inist position that the nursing
curriculum must consciously address the health care needs o f w om en
beyond the standard scientific m ode o f anatom y, pathophysiology, and
traditional obstetrics and gynecology. In addition, the course is aim ed at
heightening the students’ awareness o f the universal problems and
difficulties experienced by women throughout the world, (p. 112)
Professional issues were also addressed, such as lack o f nursing autonomy, inequity o f
financial com pensation for education, and professional status and working conditions o f
nurses. A variety o f teaching strategies was em ployed to share pow er w ith the students,
encourage experiential learning and avoid passive student learning.
Boughn collected qualitative and quantitative data to determine the effectiveness
o f the W om en’s Health Course in prom oting autonom y-related attitudes and behaviors o f
students. B oughn’s (1991) qualitative data w ere reported w ithin a descriptive article
about the course. Boughn (1991) reports the qualitative data as “rich and revealing
narratives o f the students” (p. 78). The article prim arily reports the research findings
rather than the rigor o f the study process, how ever Boughn (1991) stated that “the data
w ere analyzed by reducing raw data into concepts, coding, and then designating the
concepts to categories” (p. 78). Students w rote anonym ous responses to questions after
com pleting the course. Boughn acknowledged bias could have resulted since she was
both the author o f the questions asked and the teacher o f the course. Boughn stated there
was no mention o f the course or the teacher’s research purposes in the questions.
In data analysis Boughn grouped responses into the following categories. The
“student-educator relationship” category revealed students’ narratives about w hat was
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liked best about the course. Students verbalized enjoying the atm osphere o f the class that
encouraged student involvement in the course, and increased their perception o f freedom
and pow er as students. W hat students perceived to be the m ost helpful aspect o f the
course w as revealed in responses categorized, “changing attitudes about w om en in
general.” Students verbalized m ore awareness o f choices and options in w om en’s health
and fem inist perspectives on issues, that in turn encouraged them to be m ore assertive in
w om en’s issues. In the category, “responses specific to nursing” student nurses
verbalized greater awareness o f professional issues and the need for activism to change
the w orking condition and public im age o f nurses. N on-nursing m ajors felt they w ere also
m ore aw are o f problem s faced by nurses.
“ Responses specific to w om en in general” w as the category in w hich students
spoke about w hat w as learned about w om en’s lives. Fem inism seem ed to be the
m echanism that opened female students’ to see them selves as w om en affected by
personal and professional gender issues. Students’ responses indicated increased
assertiveness w ith boyfriends to discuss w om en’s issues that affected their lives, such as
birth control and risks for STDs. S tudents’ com m ents indicated increased identity w ith
other w om en, increased self-esteem and m otivation tow ard activism in their profession.
Responses also indicated increased aw areness o f issues im pacting health care consum ers.
These issues were concerned with violence, obstetric/gynecologic health care, care o f
breasts, infertility, and reproductive rights. A utonom y related behaviors w ere described
by students in relation to their friends, boyfriends, and parents. It w as only w ith nursing
professors that nursing students verbalized difficulty in assertive challenge. A ccording to
Bough (1991) student responses indicated “students asserted, contested, and resisted m en
in their lives,” and “revealed that they were more independent, m ore autonom ous, and
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expressed their thoughts and feelings w ithout fear” (p. 80). Bough believed this fem inist
nursing course socialized student nurses to respect them selves as w om en and em erging
nurses and linked caring to em powerm ent, necessary to prom ote em pow erm ent o f clients.
Sim ilar findings w ere revealed in Boughn and W an g ’s (1994) quantitative study
designed to study the sam e course. Q uantitative evidence w as sought to support the
hypothesis that “w om en students can be educated to accept an active role in the
advocating for both them selves as professionals and h ealth care consum ers” (Boughn &
W ang, 1994, p. 113). To collect data, a 42-item “autonom y-related attitudes and
behaviors” questionnaire w as given at the beginning and again at the end o f the course to
determ ine the extent to w hich the course affected attitudes and behaviors. Faculty
m em bers w ho teach in the departm ents o f nursing, psychology, and w o m en ’s studies
developed the questionnaire item s based on a five-point Likert scale. R eliability o f the
instrum ent w as determ ined by test-retest. A Pearson’s correlation coefficient was
established at r = 0.85. A measurem ent o f internal consistency was obtained by testing
102 nursing and non-nursing female students. A C ronbach’s alpha coefficient o f 0.85
further supported the reliability o f the instrument. C onstruct validity o f the instrum ent
was investigated using a contrasted-groups approach.
The experim ental group was made up o f tw enty-one students (11 nursing and 10
non-nursing) w ho chose to take the W om en’ Health course. Forty-three students (21
nursing and 10 non-nursing) from the university volunteered to serve in the control
group, w ho never enrolled in the course. A com parison o f pretest and posttest scores was
conducted for each group. Bias was controlled in that no incentives w ere offered for
students in the experim ental group to enroll in the course, and students w ere not asked to
participate in pre-testing until the first day o f the course. Students were inform ed that
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their responses were anonym ous and confidential and w ould have no effect on their
course grade.
Pretest scores betw een the experim ental group and control groups showed no
significant difference (p<0.05). On the other hand, the increased posttest scores o f the
experim ental group were statistically significant for tw enty-eight o f the questions. For the
control group, only three questions increased significantly over the pretest scores.
Posttest scores w ere subtracted from pretest scores from each group and compared.
Seventeen o f the questions answered by the experim ental group exceeded that o f the
control group at a significant level (p<0.05). The posttest scores for the experimental
group were all significantly (p<0.001) higher than their pretest scores, w hile the control
g roup’s pretest and posttest scores were consistent, indicating no change. The
experim ental group experienced an overall m ean increase o f 19.4 in total test score.
Boughn acknow ledged the small population studied w as a limitation. This study
w as conducted at im m ediate conclusion o f the course so B oughn acknow ledged the
research did not study the long-term effects o f the “treatm ent.” Long-term effect has only
been affirm ed through anecdotal evidence when past students w rote o r called faculty to
inform them o f instances w here this course still affected their lives. B oughn also
acknow ledged that any single feminist course in the curriculum could not revolutionize
nursing curricula, but gradual integration o f fem inist ideals and pedagogy throughout the
curriculum offered potential to promote students to be strong advocates for both patients
and nurses. The significant increases in autonom y-related attitudes and behaviors that
resulted from students taking this one course was a positive indicator that educational
practices can affect changes in nursing students.
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Beck (1995) reported on a research study conducted on the developm ent o f a
cooperative learning teaching m odel in nursing education. T he cooperative learning
m odel included principles o f feminist pedagogy. The classroom consisted o f cooperative
learning strategies. No lecture w as conducted over the fifteen-week course. W heeler and
C h inn's (1991) fem inist group process was used as the form at for group discussion. The
teacher/researcher studied the process o f cooperative and fem inist pedagogy during two
sessions o f the first professional nursing course for registered nurse undergraduate
students who w ere returning to school for their baccalaureate degree. The class consisted
o f tw enty-seven female and m ale R N students (21 in session A and 6 in session B).
Using action research throughout the course, a cooperative learning m odel was
developed that described the learning process. Students and teachers evaluated each class
im m ediately afterw ard the session. A classroom evaluation tool was developed and used
by students. The teacher kept a journal o f observations and tape-recorded observations
after each session regarding the effectiveness o f the teaching m ethods and the impact on
the classroom interactions. These observations were transcribed and significant themes
about the class w ere identified. Three sessions for each class w ere videotaped and other
faculty validated observations. The students also completed end o f sem ester evaluations.
Them es were identified from the course evaluations.
Through this process the m odel developed as four concentric circles. The
outerm ost circle depicted on the m odel represented the interplay between the course
structure, objectives, planning, and the cooperative learning strategies that offered
flexibility and context. The second circle depicted the struggles o f establishing feminist
group process, rotating leadership, and student/teacher interaction. The third circle o f the
m odel represented the classroom format: organization time, sm all group process and
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large group discussion. The outerm ost fourth circle o f the model dem onstrated the faculty
and students' interactions with each other in diverse and flexible roles.
The students and teacher reported finding the role o f the teacher to be different.
Students perceived the teacher as facilitator, resource person, and support person. A few
students felt the role to be confusing and asked fo r m ore structure. B eck perceived the
role to evolve around being the planner, clarifier, stim ulator, coordinator, and evaluator.
However, Beck believed the evaluator role was actually shared w ith students through the
form o f contracts, peer evaluation, self-evaluation, and teacher evaluation. B eck ’s
observations concluded that W heeler and Chinn’s (1991) fem inist group process
prom oted open interchange and assisted students to feel com fortable disagreeing w ith
others o r a particular author.
Student evaluations consistently indicated cooperative learning and fem inist
pedagogy to be effective means o f teaching nursing content. Strengths (Beck, 1995)
identified by students included: “ independent learning” ; “conveying respect for
students”; “being treated like an adult”; and “openm indedness o f the teacher to listen to
our view s” (p. 226).
Beck recom m ended the m odel o f cooperative learning that resulted from this
study to guide nursing faculty in future curriculum revision. The cooperative learning
model Beck developed through action research dem onstrated potential for developing a
m ore equalitarian structure and open environm ent in nursing education.
Im plications o f Research C ontext to this Studv:
These selected studies offer hope that nursing curricula can be planned and
im plem ented to change nursing education and influence student nurses’ perspectives on
nursing practice and social issues, such as the health care experiences o f w om en. The
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results o f the studies support my purposes o f proposing feminist pedagogy to raise
nursing students’ consciousness to current practices and to com e to value w om an-
centered maternity nursing care. B oughn (1991) and Boughn & W ang (1994) revealed
that nu rses’ attitudes on issues change and shift after exposure to diverse discourses. The
students’ voices in B oughn’s (1991) qualitative research exposed how the personal
connection to learning affects the professional and personal lives o f the student nurses.
Likew ise Beck (1995) and Boughn (1991) revealed how the classroom atm osphere and
the teacher’s philosophy o f shared pow er in the classroom opened the w ay for
experiential learning. Such freedom w as recognized by the students and becam e part o f
the learning experience. Boughn and B eck used their research findings to reflect upon
their teaching and describe the effectiveness o f their chosen strategies through students’
experiences. Both teachers conducted their classroom s as praxis designed to change
learning experiences and nursing practices.
The shortcom ings o f these studies are that both Beck and B oughn investigated the
experiences o f students’ learning during and/or shortly after com pletion o f the respective
course w ithout long-term follow-up. A lthough B oughn offers antidotal accounts o f the
nurses w ho later contacted her and recalled the im portance o f the class to their practices,
the studies do not investigate long-term impact on students. B o ughn’s class w as an
elective course for undergraduates w ho chose to leam about w o m en ’s health issues;
therefore her research cannot reflect on how a feminist-focused course in the required,
core curriculum , w ould be accepted by a student nurse population.
This dissertation research concerning woman-centered m aternity nursing
education and m aternity nursing practice was planned to respond to the lack o f nursing
research to investigate the impact, i f any, that feminist pedagogy and em ancipatory
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education has on nurses after they enter practice. As a feminist teacher and researcher I
planned to follow graduates who experienced feminist pedagogy in a core m aternity
nursing course and then entered m aternity practice. This research was to provide practice-
based inform ation that could move nursing education beyond studying the impact that
curriculum has on nursing students and the student-teacher relationship to investigating
curriculum as it influences nursing praxis to improve w om en’s experiences in health care
(V arcoe, 1997).
C hapter Summ ary
In this chapter I situated the theoretical context o f w om an-centered m aternity
nursing w ithin the pairing o f feminism and postm odernism . I considered Foucault’s
theory o f pow er and the ideology o f “w om an as other” as foreground to understanding
how the dom inant culture controls childbirth practices. I reviewed fem inist and
postm odern childbirth critiques in the literature to dem onstrate how fem inist and
postm odern theory are used to articulate a resistance to dom inant m edical discourses. I
described the philosophical and operational aspects o f the feminist health m ovem ent and
w om an-centered care, including factors that acted to co-opt the m ovem ent. I presented
cultural analyses to demonstrate the authoritative know ledge embedded in a technocratic
m odel o f childbirth and to identify social m ovements pressing for w om an-centered
childbirth. I addressed the relationship am ong feminism, nursing, and the patriarchy and
review ed trends in nursing scholarship, practice and education that applied fem inist and
postm odern thinking. I described the evolution o f m aternity nursing and explored the
external forces and discourses affecting m aternity nursing practices.
I presented the problematic issues surrounding childbirth practices and the
delivery o f humanistic maternity services as a call for reform in the education and
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practice o f maternity nursing. I proposed a w om an-centered m aternity nursing education
that is grounded in feminism and postm odern thinking as a path tow ard im proving
m aternity care to childbearing women. I proposed that the curriculum theories o f Patti
Lather, M axine Greene, and W illiam Pinar support the developm ent o f a wom an-centered
m aternity nursing curriculum. I reviewed nursing research studies that described how
transform ing curricula impacted nursing students’ experiences and learning.
I chose the theoretical and research contexts th at I believed significant to study
the influence that a woman-centered m aternity nursing education m ay have on m aternity
nurses in practice. The thrusts o f this chapter were to introduce fem inist-postm odern
theory, articulate the current status o f m aternity care in Western culture, and to propose
the em ancipatory potential o f feminist-postmodern pedagogy to open nurses’
consciousness to oppressive health care practices. Integrating a w om an-centered
philosophy into the teaching o f maternity nursing care w as proposed to influence changes
in nursing practices. The research process that follows in Chapter III provided a m eans to
describe new nurses’ experiences in practice after an educational endeavor in a w om an-
centered m aternity nursing curriculum.
CH A PTER m
THE RESEA RCH PRO CESS
O verview
The purpose o f this study was to uncover the meanings o f clinical practice to new
registered nurses w orking in m aternity settings subsequent to studying m aternity nursing
from a feminist perspective in a baccalaureate nursing program. Herm eneutical
phenom enology based on H eideggerian philosophy w as used to reveal the shared
practices and m eanings o f the nurses’ experiences. Heideggerian phenom enology w as
deem ed appropriate to answ er the central question o f this study: W hat is the m eaning o f
nu rses’ lived experiences working in m aternity clinical settings, subsequent to learning
m aternity nursing from a w om an-centered perspective in a generic baccalaureate nursing
course? I planned to analyze the stories o f the nurse’s lived experiences, listening for
tensions new graduates m ay have experienced in assim ilating w om an-centered care into
the realities o f practice.
In this chapter I review the research m ethodology and the purpose o f the study.
The research process that was planned is outlined, including settings, participant selection
criteria, and approaches for data generation. The procedures I planned to use as a guide
for herm eneutical analysis are briefly described. Finally, issues related to trustw orthiness,
authenticity, and protection o f research participants are addressed.
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Research D esign
Phenom enology M ethodology
Phenom enology is a philosophy and a m ethodological approach for conducting
hum an science research. Phenom enology contributes to knowledge in human science
research by seeking to achieve a deeper understanding o f the nature and m eanings o f
everyday experiences. The aim o f phenom enology is to unravel m eanings em bedded in
everyday lived experience. T he phenom enological tradition seeks to understand w hat it
m eans to be a hum an having a certain experience. This human understanding is achieved
by returning the person to the experience, w here descriptions are transcribed into text and
the essences and m eaning o f lived experience are revealed through reflective analysis o r
interpretation (M oustakes, 1994; van M anen, 1990).
Consistent w ith a qualitative research m ethod, descriptions o f experiences are
accepted as recalled from the perspective o f th e person who lived through the
phenom enon under study. T his em ic perspective o f the everyday life world is studied
from a naturalistic setting w here context is considered part o f the phenom ena. The
researcher does not seek to control o r guide the study with pre-conceived ideas (M orse &
Field, 1995).
Phenom enologic approaches to human science research provide a m eans for
looking at the wholeness o f experience rather than objects or parts. Subject-object and
parts-w hole are integrated. M eanings and essences are sought, rather than explanations or
m easurem ents. Experience is held up as em pirical evidence in understanding hum an
beings in a scientific investigation. D ata are m o st often collected through personal
interview s and dialogue betw een a study participant and the researcher, yet, artw ork and
other poetics are also possible m edium s for revealing meaning. Personal interest and a
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high level o f involvement are required from the researcher conducting phenom enology
(M oustakes, 1994).
Phenomenological research m ethodology is founded on the philosophical
underpinnings o f the phenom enology m ovem ent. Phenom enology as a philosophical
tradition evolved through the w orks o f philosophers in the early twentieth century, m ost
notably, H usserl, H eidegger and Gadamer. Transcendental (descriptive) and hermeneutic
(interpretive) traditions em erged w ithin the philosophical m ovem ent (C ohen & Ornery,
1994; M acann, 1993; M oustakes, 1994; Stew art & M ickunas, 1990). The distinctive
philosophical underpinnings o f descriptive and/or interpretive phenom enology are
clarified by the researcher prior to beginning phenom enological inquiry.
Phenom enology originated from a philosophical quest to explain th e notion o f
hum an presence in the world. Edm und H usserl, the father o f phenom enology, began a
search for an eidetic science to challenge the Cartesian division o f reality into mind and
body. This subject-object dualism led to irreconcilable schools o f philosophy, rationalism
and empiricism (Stewart & M ickunas, 1990).
Husserl founded Transcendental Phenom enology based on his b e lie f that life and
m eanings are constituted through conscious awareness. H usserl called for a return “to the
things them selves" (M oustakes, 1994, p. 26), representing a Cartesian spirit o f mind w ith
a radical new perspective. H usserl considered anything in w hich one is conscious to be a
phenom enon. From an epistemological foundation, Husserl contended that conscious
awareness represents the hum an’s reciprocal relationship w ith the world and is the only
m edium through which the life-world can be known (Stewart & M ickunas, 1990).
A ccording to H usserl, consciousness always "intends" a determ inate som ething as its
object. Consciousness is always a consciousness "ofsomething" (Husserl, as cited in
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W achterhauser, 1986, p. 27). Husserl’s philosophy challenged the view that
consciousness exists only in thoughts and em otions o f the mind and is closed o ff to the
external physical world.
C onsistent with transcendental philosophy, H usserl believed that know ledge o f
objects com es through experiences w hich are conscious to the subjective self. W ithin this
transcendental subjectivity, the know ing ego reflects deeply on itself, w hile bracketing or
holding in abeyance preconceptions about the phenom ena. This bracketing is called
Epoche, m eaning "to refrain from judgm ent, to abstain from o r stay away from the
everyday, ordinary way o f perceiving things" (M oustakes, 1994, p. 33). T his bracketing
o f suppositions frees one from "the natural attitude," or the usual attitude regarding the
perception, judgm ent and thought about the subject studied. Through a process o f
reduction, each experience is perceived, reflected upon and described in its totality. It is
w ithin this reflective process that the intuitive-thinking s e lf appears who affirm s, senses
or doubts. The meaning o f that experience reveals itself and becom es the essence. This
unity o f the experience and meaning is referred to as a "science o f essences." This
essence becom es the distinguishing qualities o f the phenom enon, without w hich the
"thing" w ould not be what it is (M acann, 1993; M oustakas, 1994; Stewart & M ickunas,
1990). Em bedded in Husserl's transcendental tradition is the assum ption th at once the
decision for reflection occurs, consciousness autom atically results and the pure essence
reveals itself (W estphal, 1986). This b e lie f continued to support the Cartesian assum ption
that the mind is more easily known than the body.
H usserl's ideas o f phenom enology provided im petus for the science o f lived
experience to undergo further philosophical m ovem ent as philosophers studied and
sought to clarify beliefs divergent to H usserl's writings. M ost notably H eidegger’s
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perspectives rejected the science o f essences. H eidegger was concerned with an
ontological perspective, asking w hat does it m ean to be a person? Heidegger (1927/1962;
1953/1959) m oved tow ard existential phenom enology, believing that understanding lived
experience cam e through "Being-in-the-world," w here the observer cannot separate
h im se lf from the w orld. H eidegger dismissed H usserl's idea o f bracketing, believing
instead that experience is interpreted in a situated w orld-context, resulting in
"consciousness o f reality" (W achterhauser, 1986, p. 27). All hum an actions, thoughts,
and em otions define the context in which the person is situated. Through engaging in the
w orld, the person grasps m eanings and becom es a self-interpreting being. H eideggerian
phenom enology begins with practical, concerned engagem ent w ith a phenom enon
(H eidegger, 1927/1962; Macann, 1993).
The sense o f B eing H eidegger presents for study is em bodied as a person in the
physical world. T hus Heidegger's philosophy seeks to explain the meaning o f bein g a
person engaged in the world. Leonard (1994) sum m arizes the H eideggerian concept o f
person as "the person as having a w o rld ...; the person as a being for whom things have
significance and v a lu e ...; the person as self-interpreting...; the person as em b o d ied ...;
and the person in tim e ..." (pp. 46-58).
H eidegger represents hum an reality or existence as D asein ("being-there"). The
term D asein em phasizes that hum an existence is alw ays situated in the world. D asein is
the place w here B eing reveals itself through tim e - providing an opening toward B eing
(Stew art & M ickunas, 1990). "D asein always understands itse lf in term s o f its existence -
in term s o f a possibility o f itself: to be itself or not to be its e lf’ (H eidegger, as cited in
M acann, 1993, p. 61). The search for understanding o f an authentic Dasein or existence
in the w orld is at the heart o f Heideggerian phenom enology.
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H eideggerian philosophy presents the person experiencing "throw nness," in the
w orld (Leonard, 1994, p. 49). T he person finds itself constituted by a physical body with
traits and bound to the world through culture, language and historical placem ent. This
world context defines the person and influences future human action. B ackground
m eanings are form ed from sharing the world w ith others resulting in a public
understanding o f com m on practices. The world context that constitutes B eing-in-the
w orld is often so taken-for-granted that this world only appears w hen there is a
breakdown.
Being-in the world for the person m eans that things, including people, matter.
The significance o f things that m atter is also related to the context o f the situation and the
background m eanings shared w ith others in the w orld. The significance o f things is what
m otivates the person to stay involved in the world, what H eidegger calls "concern"
(B enner & W rubel, 1989, pp. 47-48).
The em bodied person engages in the world w ith shared com m on practices and
perceptual capacities. The body is the person's basic mode o f being in the w orld
becom ing the em bodied consciousness. The body provides situational context and cannot
be view ed as a thing separate from its intentionality. The union o f consciousness and
body provides the origin for all action in the world. Involvement o f the body in the world
is often taken-for-granted until som e breakdown occurs (Leonard, 1994). H eidegger
distinguished the seem ingly transparent and sm oothly functioning body in the w orld as
the "ready-at-hand" (Plager, 1994, p. 73), w hereby the person is involved in everyday
activities in the w orld without m uch conscious thought. When breakdow n o r disruption
occurs in the sm ooth functioning o f the body, such as illness, the "unready-to-hand"
(Plager, 1994, p. 73) brings the taken-for-granted activities in the w orld to conscious
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awareness. Interpretative phenom enology can offer access to study the person situated in
both “ready-at-hand” and “unready-to-hand” worlds o f involvement.
The person engages in the world through time. Heidegger presented time, not as
em pty space to fill, rather as directional and relational to Being. Tim e is related to Being
as events, activities and content that makes up tim e living in the w orld. Being-in-tim e
involves the person's awareness o f having-beeness and being-expectant. This constitutes
the person as having both a past and future. Possibilities are opened for the future o f
becoming (Leonard, 1994; M acann, 1993).
Human understanding occurs through the shared context o f living in the w orld
w here experience and Being are revealed through language. Researching lived experience
within Heideggerian philosophy is an act o f interpretation known as hermeneutics. The
goal o f herm eneutics is to “understand everyday skills, practices, and experiences; to find
com m onalities in m eanings, skills, practices, and embodied experiences” (Leonard, 1994,
p. 56). The m eaning o f everyday practices is em bedded in the text and emerges w ithin
exem plars and paradigm cases that situate the person in the context o f the experience.
Lived experience is interpreted through narrative text, where the shared m eanings
o f the authored text and the researcher become explicit through w hat Gadamer called a
"fusion o f horizons." As G adam er (1977/1990) stated, "Language is the fundamental
m ode o f operation o f our being-in-the-w orld and the all-embracing form o f the
constitution o f the world" (p. 147). The native language and specialized languages o f
fields o f study are inherited and shape the person's being. Language is the primary
vehicle for transporting the past into the present and future. G adam er (1977/1990)
believed that “ Language occurs...in vocabulary and gram m ar as alw ays, and never
w ithout the inner infinity o f the dialogue that is in progress between every speaker and
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his partner" (pp. 157-158). It is "genuine speaking," that G adam er (1977/1990. p. 158)
recognized as the "universal hum an task" necessary for one person to reach another
through language w ithout pre-arranged signals.
H erm eneutics requires the interpreter to be conscious o f prejudices th at constitute
being and to reflect upon those prejudices during the process o f interpretation. Language
and history are considered "always both conditions and limits o f understanding"
( W achterhauser, 1986, p. 6). H istory impacts the possibilities and perspectives available
for understanding a phenom enon. G adam er called for the researcher to transcend the
prejudices that underlie the aesthetic, historical, and herm eneutical consciousness that
may direct experiences. Com ing to understanding the new w ithin situated prejudices are
acknowledged through the hum an relationship. G adam er (1977/1990) considered each
person a "kind o f linguistic circle, an d these linguistic circles com e into contact w ith each
other, m erging more and more” (p. 157). This dialectical m ovem ent inherent betw een the
text and the interpreter is acknow ledged as the herm eneutic circle (Thom pson, 1990).
W ithin the herm eneutic circle space is allowed for the interpreter and research participant
to work out the understanding and explore richness o f the m eanings and lim itations to
understanding. The nature o f the herm eneutic circle is to sym bolize that there is no
perfect m echanical m anner to interpret data. G adam er's thinking asserts that the process
o f understanding is alw ays fluid, open, and never achieves finality (Pascoe, 1996).
Critical herm eneutics was a response o f philosophers from the Frankfort School
o f Critical Theory to recognize that interpretation m ay be flawed and must be questioned
around dom ination o f the individual. Critical hermeneutics calls one to go beyond the
m ost obvious interpretation and to keep a suspicious attitude in looking for m eanings
(Thom pson. 1990). Fem inist theory w as used as a critical lens to interpret cultural
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m essages o f oppression em bedded w ithin lived experiences o f nurses in this study. Using
this perspective in existential phenom enology affirm s the cultural identity o f w om en as
an oppressed group and offers opportunity to liberate women. R aising consciousness o f
fem ale oppression through fem inist interpretation can bring w om en to shed the ideology
o f "otherness" internalized from living in a sexist society. Such freedom renew s
possibility for the becom ing o f the authentic s e lf (Donovan, 1992).
M ethodological approaches used in this study were planned to be consistent with
the philosophical underpinnings o f H eideggerian phenom enology. The philosophical and
m ethodological underpinnings o f herm eneutical (interpretative) phenom enology were
appropriate to studying nurses’ experiences in m aternity practice. H eideggerian
phenom enology offered a m ethodological approach to "uncover com m onalties and
differences, not private idiosyncratic events o r understandings" surrounding nurses
experiences in practice after being educated w ithin a w om an-centered philosophy
(B enner, 1994. p. 104). The dialogue with research participants and interpretation o f the
transcribed texts were guided by the herm eneutical process to explore the five sources o f
com m onality related to the nurses’ experiences in m aternity practice: situation,
em bodim ent, temporality, concerns, and com m on meanings (B enner, 1994). The
herm eneutical m ethodology provides a process for studying texts as a w hole to elicit
generalized meanings. The data analysis process includes extracting specific them es and
m eanings from within each interview to generate constitutive patterns com m on to the
research participants’ experiences. Exemplars and paradigm cases are identified that
support themes and constitutive patterns across all texts. A research team m ade up o f
m y self and two experienced qualitative researchers was planned to read each text in
totality to interpret m eanings and reach consensus on themes and patterns. A s the
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researcher I planned to make the final decisions regarding data analysis i f and when there
w as disagreem ent in interpretation o f data am ong the research team.
Setting
The registered nurse participants in this study w ere expected to be representative
o f the student population o f the nursing program from w hich they graduated in the
southeastern United States. It was anticipated that the m ajority o f nurses w ould be
C aucasian women between 22 and 40 years o f age. A pproxim ately 20% o f the graduates
o f this program represented minorities, including men. Ethnic diversity w as anticipated
am ong the participants, although I did not expect to find m en working in the maternity
nursing area. I knew male nurses were not com m only accepted into m aternity practice
areas due to prejudices o f health care institutions and sta ff toward male caregivers during
childbirth. This represented a paradox, in that male physicians and anesthesiologists were
accepted as the norm. The image o f m aternity nursing as a female specialty generally
influences men in nursing to seek other specialty areas and roles.
The first class to graduate who experienced m aternity education from a wom an-
centered perspective was in Decem ber 1996. Therefore, the nurses expected to participate
in the study would have worked in m aternity settings no m ore than three years, but as
least six months. I expected the registered nurse participants to represent em ploym ent
from both private and public hospital settings throughout m etropolitan com m unities that
offer m aternity services. I expected the hospital birth rates w ould vary from 50 deliveries
a m onth in sm aller private hospitals to 300 a month in larger public and private hospitals.
I anticipated that nurses who worked in public settings w ould experience m ore contact
with w om en o f low er socioeconomic status and women o f racial m inorities. However,
som e private hospitals also service w om en receiving state m edicade reim bursem ent.
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The state from which I anticipated the m ajority o f participants w ould be em ployed
ranked fiftieth am ong the states in midwifery attended live births in 1996 (M organ &
M organ, 1999). O nly 0.7% o f all births in the state were attended by m idwives, m uch
low er than the national average o f 6.5% in 1996. M eanw hile, the cesarean birth rate in
1997 represented 25.4% o f all births in the state, exceeding the national average o f 20.8%
(Ventura, Martin, Curtin, & M atthews, 1999). T he state’s cesarean birth rate was
exceeded by only one other state. There were no nurse o r direct-entry m idw ifery school
in the state. The two medical schools in the state focused o n teaching medical
intervention for birth. There were no midwives employed b y these schools to teach
m edical students the m idwifery paradigm. Therefore, I anticipated that m aternity care
throughout the state would be strongly influenced by a m edical model o f care and that
nurses practiced in medically-controlled, traditional care environm ents. I expected each
hospital to have policies that prom oted family presence d u rin g the birth process and
m arketed themselves as “family centered” settings, although birth alternatives w ould be
lim ited to common medical rituals. There were no birth cen ters and few m idw ives
available within the state. Therefore, midwifery birth was n o t an option open to m any
w om en and few nurses experienced this model o f childbirth care.
I realized the culture o f the area was strongly influenced by Catholicism, w hich
intertwines women and childbearing with religious beliefs. I anticipated that w om en w ere
socialized to follow traditional roles to marry and have children. I believed there w ere
strong community objections to abortion and negative attitudes about the use o f birth
control outside o f marriage. In 1990, one o f the strongest anti-abortion laws in the U nited
States passed the state legislature, but was later declared unconstitutional. This law w ould
have allowed rape, incest, or life o f the m other to be the o n ly reasons for abortion. The
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religious foundations that encourage w om en to bear children do not provide w om en
positions o f authority within religious institutions. I realized w om en’s rights to autonom y
and decision-m aking were limited due to cultural and church beliefs about gender. I
believed these factors combined to support a culture o f medical care where the w om an-
consum er w as socialized to look to m ale authority to offer direction.
Participants
Phenom enologic research requires that participants are persons who have
experienced the phenom enon o f concern and are w illing and ready to speak about it
(M unhall, 1994). M aternity nurses in this study shared the experience o f entering
m aternity practice after being educated about w om an-centered m aternity care during their
undergraduate m aternity course. I planned to specifically seek nurse participants w ho
took the baccalaureate maternity nursing course that m y colleagues and I developed and
taught. W e designed this course to teach a w om an-centered philosophy o f m aternity care,
using postm odern and feminist pedagogies (G iarratano, Bustam ante-Forest, & Pollock,
1999).
I realized researching the experiences o f nurses w ho were m y past students
presented opportunities and problem atic issues. R esearcher and fem inist teacher Patti
L ather (1991) studied her current and past students regarding the effects o f im posing
liberatory education on young women in her classroom . Lather characterized her research
as self-reflexivity necessary for the fem inist teacher. C onsistent w ith Lather, I believed
researching m y former students would offer an opportunity for m e to reflect upon m y
ow n pedagogical practices. I had the opportunity to reflect upon w ays the feminist
discourse o f w om an-centem ess affected the clinical practice and lives o f nurses in
m aternity practice. I anticipated my personal know ledge about the students’ curriculum
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would strengthen the study. I was ensured that all the potential participants w ere exposed
to a philosophy o f w om an-centered m aternity nursing prior to entering practice -- the
phenom ena o f concern. I knew the ways that the notion o f w om an-centered m aternity
care was presented in the context o f the graduates’ nursing curriculum . I had know ledge
o f the clinical learning activities and specific course assignm ents that supported the
awareness o f this philosophy. W hen the nurses spoke to these activities during the
interview, I knew I w ould have know ledge o f the assignm ent and could pose questions
and achieve a level o f understanding that m ight not have been possible w ithout this
knowledge. O n the other hand, I realized I had to exercise caution in being so close to the
nurses’ educational experience that I took-for-granted and overlooked salient inform ation
due to fam iliarity or pre-determ ined m eanings.
I realized the pow er relations betw een m y self and the participants w ere
potentially the m ost problem atic issue. In m y previous relationship with the research
participants I was in the role o f university faculty and they w ere undergraduate nursing
students. Regardless o f m y teaching style, the nurse faculty role inherently set up
institutional pow er relations w ith students that is associated w ith surveillance,
disciplinary techniques and norm alization o f behavior (Foucault, 1975/1977; 1977/1980;
G ore, 1992). A s researcher, I knew I had to be aw are o f this past history and w ork to shed
the authoritative aura o f teacher. The participants nor I could ever escape o u r past
relationship; however, it w as m y plan to strive to alter the pow er relations and set up a
relationship based on a collegial, mutual interest o f two nurses -- one in practice and one
in nursing education — w ho w ere com m itted to understanding m aternity nursing practice.
I planned to im plem ent strategies during the interview process to address these concerns.
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I anticipated the study participants to be newly graduated nurses w ho entered
practice in a m aternity clinical area within a y ear o f graduation and had w orked there
betw een six m onths and three years. I anticipated m aternity clinical areas w ould include
antepartal, intrapartal, or postpartal-w ell new born care settings. I planned to recruit at
least twelve participants from among graduates w ho experienced the w om an-centered
philosophy in their undergraduate m aternity course. Initially, I planned to contact
potential participants who I knew w ere w orking in hospitals as maternity nurses in the
local geographical area. I planned to seek referrals from the initial participants, inquiring
i f they knew any graduate peer who was also w orking as a m aternity nurse. I planned to
ask the faculty and adm inistration from the school to inform m e o f names o f graduates
they knew w ho w ere w orking in maternity practice. I also intended to advertised the
study in the school’s alumni new sletter asking new graduates who met the criteria to
contact me.
I planned to conduct an in-depth open-ended interview o f approxim ately one hour
with each participant. Interview s were to focus upon the graduates’ descriptions o f their
everyday practices as m aternity nurses, the values that guided their practices, and the
enabling and/or constraining factors to m aternity nursing practice. I planned to have the
audiotaped interview s transcribed verbatim to serve as the text for analysis. I planned to
listen for “redundancy” o f data in the texts to determ ine w hen the number o f participants
was sufficient (Lincoln & G uba, 1985).
Data Generation Strategies: The Interview Process
I anticipated that this research study w ould generate data by fostering
“collaborative herm eneutic conversation” (van M anen, 1990, p. 99). I intended for
dialogue betw een m yself and research participants to be stim ulated by open ended
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questions used to keep me and the participant involved in conversation aimed at
interpreting the m eaning o f wom en-centered m aternity nursing education and m aternity
nursing practice. T he dialogic structure o f questioning was considered a “herm eneutic
thrust” to understanding the phenom enon. The collaborative nature o f the interview w as
intended to be directed toward the researcher and participants' mutual interpretation o f
the phenomenon. I realized questioning to bring “ Being-there” into aw areness “only
opens up the horizon” (Heidegger, 1953/1959, p. 29) to identify the phenom enon w ithin
the context o f the person.
Strategies w ere planned to create a non-hierarchical relationship with the nurse
participants. As a faculty member in the m aternity nursing course, and the school o f
nursing from which the participants graduated, I planned ways to distance m yself from
the image o f an educator seeking to teach them o r critique their perform ance as a nurse in
practice. I planned to approach potential participants in an informal, relaxed, and
collegial manner, beginning with personal contact o r a telephone conversation to elicit
initial interest. I planned to approach the nurses identifying m yself as both a nursing
student-researcher and a maternity nurse educator who was genuinely concerned w ith
their experiences in practice and who w as seeking to gain knowledge through their lived
experience that m ay benefit nurses, educators, and childbearing women. I intended to
articulate the focus o f the study on the im portance o f lived experiences in m aternity
nursing practice. I planned to request a first name protocol with the potential participants
and dress inform ally during the interview. I anticipated choosing places for informal
interview s that w ould encourage and free the participant to speak w ithout restraint
concerning their nursing education and practice. I planned to choose places convenient
and m utually agreed upon, such as a hom e, office setting, or private conference room
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reserved in public locations, such as libraries, universities o r hospital settings. I avoided
offering m y faculty office at the school o f nursing in order to distance m y im age as
faculty.
I planned that potential participants w ould receive a letter prior to the
interview that explained the purpose o f th e study and the researcher and
participant’s roles in the research process (A ppendix A). In the letter, I posed five
questions and asked the participants to th in k about these questions prior to the
interview . The questions included:
1. W hat are your mem ories o f learning w om an-centered m aternity care in nursing
school?
2. W hat does learning a w om an-centered philosophy o f care m ean to your current
practice?
3. D escribe particular clinical situations that stand out for you in your clinical
practice.
4. W hat beliefs about m aternity care influenced your role in these clinical situations?
5. W hat does being a m aternity nurse m ean in your personal life?
A t the beginning o f each interview , I planned to review the purpose o f the study,
explain the interview process and obtain w ritten consent (A ppendix B). Consents w ould
be m ailed in advance to those participants w ho must be interviewed by telephone due to
geographical distance. I planned to begin th e interview process by asking the participant
to reflect upon their memories o f w om an-centered m aternity education, then proceed into
the potential m eanings their prior education had on their current practice and personal
lives. I planned to use the open-ended questions posed in the letter as an opening for the
nurse to share their experiences. Through th e em ergent dialogue, I anticipated asking
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m ore specific questions as needed to clarify m y understanding o f the participant’s
perspective o r to elicit richer descriptions o f experiences.
Participants would be asked to participate in follow-up interview s at the
com pletion o f the initial interview. I planned follow-up interview s to be conducted in
person or by telephone in order to verify the transcribed text and the research team ’s
interpretation o f the meaning o f their experiences. I planned to provide a copy o f the
transcript to each participant and to share a copy o f the study findings, including the
identified patterns and themes.
D iekelm ann and A llen’s H erm eneutical Process o f Analysis
The goal o f hermeneutic interpretation is to com e to consensual validation o f the
skills, practices, and com m only shared meanings revealed in the research text (Leonard,
1994). The herm eneutical process includes aw areness o f background meanings in culture
and language that influence the interpretation b y the researcher and the participants. The
interpretative process is a circular process, m oving between parts o f the text and the
w hole. The interpreter is aware o f preunderstanding or forestructure that initially
influenced understanding o f the phenomenon, w hile sim ultaneously rem aining open to
understanding w hat the research data reveals. A n authentic, deep understanding is sought
- - that goes beyond what is assumed in the forestructure. As researcher, this dem anded
that I stay engaged w ith the text and honor the lived experience o f the research
participants as the focal point for interpretation. T he interpretative process for this study
w ould include analyzing each nurse’s text for a global analysis. Them es and categories
that consistently em erged among the texts were to be identified. Exem plars or vignettes
that captured m eanings in situations and paradigm cases that em body rich descriptive
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patterns o f meanings from situations were to be connected w ith the themes and categories
(Leonard, 1994; Plager, 1994).
The interpretative analysis o f this study was based upon a seven step critical
herm eneutical process described by Diekelmann and A llen (1989). I anticipated the
m ultiple stages o f the research process would provide opportunity to expose conflicts and
inconsistencies that could occur during analysis. I anticipated that the interpretation
process w ould provide opportunity to reappraise data as conflicts in analysis occurred. I
present a b rief sum m ary o f the seven stages for analysis.
Stage one involves each m em ber o f the research team reading the w hole text o f
each participant. In this initial examination o f text each researcher seeks overall
understanding from the text. In stage two each m em ber o f the research team summarizes
sections o f the docum ent that support identified categories. The research team dialogues
until consensus is reached regarding the analysis o f data that supports categories. In stage
three each team m em ber’s interpretation o f the categories is com pared to the
investigator’s for consistency or differences. The text is used to clarify any discrepancies
(D iekelm ann & Allen, 1989).
In stage four relational them es are identified. Texts are re-read to identify similar
or contradictory m eanings am ong participants. Docum entation is required to substantiate
support for the choice o f relational themes. Stage five involves the developm ent o f
constitutive patterns w hich cross all the texts and express the relationships am ong the
relational themes. In stage six the researcher validates the entire analysis to m em bers o f
the research team and w ith interpretative researchers who are not members o f the team.
Stage seven involves preparation o f the final data analysis w ith excerpts from the
interview texts, along w ith paradigm cases and exemplars, to validate findings.
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I intended the interpretations would be validated with participants, two o th er
qualitative researchers, and m y faculty advisor. I also planned to keep a journal to record
m y feelings, thoughts and decisions that im pacted the research process, beginning w ith
the recruitm ent and interview processes and throughout data analysis.
As I anticipated using D iekelm ann and A llen’s method o f d ata analysis as a guide
for interpretation, I was aw are that no m ethod could guarantee a “correct” interpretation
o f the nurses’ experiences. As David Allen (1995) states, no foundationalist “co rrect”
meaning exists, rather “interpretation is an interaction between a historically produced
text and a historically produced reader” (p. 175) that requires concerned engagem ent with
the research data. Using a “ m ethod” for interpretation represents values o f a m odem
w orld that looks for precision, prediction, and certainty (Doll, 1993). L ike other
qualitative researchers, I struggled with the sim plicity o f explaining interpretation
through a series o f steps — w hen determ ining m eaning through qualitative research is a
com plex and artful experience (Sandelow ski, 1993, 1994; van M anen, 1990).
A postm odern perspective on qualitative data analysis reveals the lim itation o f
ever producing a precise analysis. I realized the nurses’stories o f experience, the
transcribed text o f the interview s, the field notes, the m em ories o f conversations and the
evolution o f m eanings from the data w ould be filtered through the com plexity o f history,
tem porality and m ultiple m eanings em bedded in language. As D errida (1982/1991b)
explains in his notion o f differance. there is never a tim e when the text rem ains stationary
in meaning, rather m eaning is constantly “deferred.” I realized each tim e the transcribed
text was read it would be reread as new. The m eanings o f the text w ould change w ith
each reading because all participants (the nurses, the research team, and m yself) w ould be
influenced by the passage o f tim e and new experiences. I knew from the tim e I
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anticipated initially interview ing research participants to the tim e I asked them to read the
transcribed text, new life experience w ould impact the nurses’ perspectives. T he nurses
w ould have time to reflect on the interview and live through new experiences in
m aternity nursing practice. Likew ise the research team and I w ould have interpreted
m eaning from the interview text w hile tim e and history impact o u r understanding o f this
data. I realized the m ultiple m eanings em bedded in language and experiences challenged
the possibility o f us coming to consensus on data interpretation (D errida, 1988). I
anticipated that through thoughtful engagem ent w ith the texts and discovery o f rich
descriptions in the text, data interpretation could evolve that represents a panoram ic
“snapshot” o f these nurses’ experiences at this identified time. I realized this fleeting
view w ould offer a m ere glim pse into understanding the phenom enon o f w om an-centered
m aternity nursing education and new graduates’ experiences in practice w ithin the
context o f this study.
Trustw orthiness
Trustworthiness o f qualitative, research involves an intellectual process for
ju d g in g if the inquiry is “m ethodologically and analytically sound” (Lincoln, 1990).
Lincoln and Guba (1985) established the “trustworthiness criteria” that included elem ents
o f credibility, transferability, dependability, and confirmability to serve as standards for
designing and evaluating the process o f naturalistic inquiry. The trustw orthiness criteria
was addressed in this study to assure confidence in the processes and outcom es o f the
study. O nly as the research study is determ ined trustworthy by others can the credibility
o f the study be w arranted. The ju d g m en t o f credibility is ultim ately m ade by the
consum er who wishes to relate the study findings. Techniques used by the researcher
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never achieve absolute p ro o f o f authenticity, but only act to persuade the consum er to
accept the study findings as credible.
Credibility
The credibility or truth-value o f phenom enological research is concerned with the
adequacy in which the multiple realities o f research participants are reconstructed in the
study (Lincoln & Guba, 1985). The descriptions, interpretations, and m eanings captured
from the research data were expected to be authentic representations o f the hum an
experience under study. I anticipated using audio tape-recorded interview s w ith open-
ended questions to elicit personal accounts o f experiences as the prim ary m ethod for
obtaining data. I planned for the essence o f th e phenom enon to be represented in the
w riting o f the research findings. The credibility o f phenom enology research lies in the
phenom enological description, van M anen (1990) states, "a good phenom enological
description is an adequate eludication o f some aspect o f the lifeworld -it resonates with
our sense o f lived life" (p. 27).
In this study I planned to address credibility through a num ber o f avenues
recom m ended by Lincoln and G uba (1985). Prolonged engagem ent in teaching and
studying feminist pedagogy in m aternity nursing education has been achieved through
m y ow n lived experiences as a teacher, m aternity nurse and doctoral student. These
experiences prepared me to recognize distinguishing characteristics o f nursing education
that raise consciousness about oppression o f nursing students, nurses, and w om en clients
in m aternity practice areas. I taught in the m aternity nursing course the past three years
using a w om an-centered philosophy while still practicing and teaching in m aternity
clinical settings where woman-centered care w as not valued. This provided m e insight
into the potential questions to ask in order to gather the nurses’ perspectives on their lived
1S6
experiences. However. I also acknowledged this as forestructure to the study that I
needed to be aw are o f as I entered into dialogue w ith nurses and as I sought to interpret
data without pre-set expectations. As researcher, I identified preconceptions about the
phenom enon, but I intended to question the participants without m y questions pre
defining the phenomenon. As Leonard (1994) points out, credibility in an interpretative
study also requires that the researcher lay out "preconceptions, biases, past experiences,
and perhaps even hypotheses that make the project significant fo r the investigator and
that m ay affect how the interpretation takes shape" (p. 72). Personal knowledge,
experiences, assum ptions and biases o f the researcher as a result o f this phase o f
prolonged engagem ent were acknowledged prio r to beginning study in o rd er to reveal
how these may affect the study.
I anticipated that prolonged engagement in the research w ould also be confirm ed
through the interview process w ith participants. I anticipated interview ing at least twelve
participants over a three m onth period o f time. I planned to interview each participant for
approxim ately one hour during an initial session. The text and th e research interpretations
w ere to be shared w ith the research participant at a subsequent m eeting o r by m ail. I
planned to conduct interviews a second time, should either the participant o r researcher
identify a need to clarify the initial text.
I intended to establish a trusting relationship with the nurses as a foundation to
eliciting “truthful” and rich descriptions o f their experiences. A ccording to Lincoln &
Guba (1985, p. 303), as researcher I must engage in a "developmental" process w hereby
the new ly graduated nurses sense that my interest in research centered upon concern with
their experiences, as the heart o f the inquiry. I intended to distance m yself as a teacher
and identify m yself as a nurse colleague and a researcher wanting to learn from their
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experiences. I planned to establish rapport and maintain an inform al atm osphere w ith the
participants. A concerned presentation o f self, including verbal and non-verbal
com m unication and a causal physical appearance were variables that I believed w ould
impact perceptions. I realized that genuine talk w ould be required to transm it concern and
interest for the graduates’ personal experiences. I planned telephoning potential
participants and explaining the study prior to the actual interview session to contribute to
the developm ental trust-building.
I planned to validate m y interpretations o f the text by a series o f peer debriefings.
I intended to ask experienced researchers to participate in the herm eneutic process as
outlined by Diekelm ann and A llen (1989). I expected experienced researchers on the
team to consist o f two nurse researchers who are experienced in qualitative research and a
faculty advisor at G eorgia State University. I planned for the data analysis process to
provide opportunity for peer debriefing by a disinterested but experienced qualitative
researcher w ho could review’ the prelim inary findings and offer critical judgm ent
concerning the analysis. A nother nurse researcher w ould also be asked to review the final
analysis. I believed the herm eneutic process w ould keep the interpretation grounded in
the lived experiences o f the participants. I intended to link excerpts o f the text to the
them es and constitutive patterns that em erged am ong all texts. I planned to listen for rich
descriptions o f lived experience that pointed to recurring them es and patterns w ithin the
context o f the nurses’ practices. M orse & Field (1995) point to the "researcher-as-
instrum ent," (p. 141) in recognizing that quality o f data and the depth o f analysis is
dependent on the researcher's engagem ent in the study.
I planned further evidence o f credibility through m em ber checking. I intended for
each research participant to receive a verbatim transcript o f th eir interview to review for
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accuracy. I planned to enclose a self-addressed envelope for returning the corrected
transcript to me. In event the transcript was no t returned w ithin two weeks, I planned to
call participants to remind them. A fter receiving the corrected transcript I planned to
m ake a follow-up telephone call to discuss and clarify corrections. I intended to schedule
a follow-up interview if deemed appropriate b y either the participant or m y self to review
aspects o f the text needing more explanation. A t the conclusion o f the study, I planned to
m ail each participant a copy o f the findings and m ake telephone contact again to seek
th eir responses to the findings. A ny expressed concerns o r differing opinions from the
participants w ere planned to be shared and discussed w ith the research team. I planned to
have these concerns included in the final report, i f indicated.
T ransferability
T ransferability is the criterion used to determ ine w hether the findings can be
related to som e other context, setting, or another population (Lincoln & Guba, 1985).
D ata interpreted through qualitative m ethodology does not claim to be generalizable to
o th er populations o r situations. However, acknow ledging the context o f the study is
central to supporting transferability o f the findings to other circum stances.
I planned to report thick description from excerpts o f the texts that substantiate
th e recurrent patterns that represented the phenom enon o f w om an-centered m aternity
nursing education and the lived experience o f new graduates in practice.
C onfirm abilitv
C onfirm abilty criteria seek to ensure that both the research procedures and data
anaylsis are free from bias. To provide evidence o f confirm ablity, I intended to keep a
reflective journal to record the decisions and report self-participation in the data analysis.
T his w ould establish confirmability through an audit trail that described and ju stified
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what was done and why (Lincoln & Guba, 1985). The audit trail records subjective
influences that m ay affect the study process. O f special concern are how the data are
described, interpreted and how decisions are made to include o r exclude categories or
them es (K och, 1994; Sandelowski, 1986; 1993). Audit trails are also seen as a way to
ensure w hat Lincoln & Guba (1985) consider dependability o f the study. However, the
issue that dependability should correspond to reliability is challenged by nurse
researchers. Sandelowski (1993; 1996b) and Leonard (1994) point to the plurality o f
interpretations and multiple realities o f truth as the indeterm inate nature o f qualitative
research that m akes any notion o f repeatability o f research findings unwarranted.
Authenticity Criteria
The authenticity criteria were proposed by Guba and Lincoln (1989) and Lincoln
(1990) to devise techniques o f evaluation rooted in a naturalist paradigm. Trustw orthiness
criteria, w hich parallel rigor in positivist research, work to ensure that the research
m ethods are adequate. Authenticity criteria go beyond the prim acy o f m ethod to design
other techniques to ensure that the stakeholders' constructions o f reality have been
collected and fairly represented and to assess for actions stim ulated through the research
study that indicates involvement o f the stakeholders. The authenticity criteria
recom m ended for naturalist inquiry that were planned to be addressed in this study were
fairness, and ontological, catalytic, and tactical authenticity.
“Fairness refers to the extent to which different constructions and th eir underlying
value structures are solicited and honored w ithin the evaluation process” (G uba and
Lincoln, 1989, p. 245-246). The researcher is obligated to seek out and clarify all
positions and values that emerge from the participant’s different constructions o f the
research phenom ena. I planned to use an audit trail to validate m y efforts to seek out all
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potential participants for this study to provide a diversity' o f voices and perspectives.
D uring the interview process and reading the texts, I planned to listen for opinions and
conflicts concerning the phenom ena that differed from mine. D uring content analysis o f
the data I intended to be sensitive in representing these perspectives. The faculty advisor
and the research team were in place to further question any interpretations that failed to
consider appropriate representation o f the stakeholder’s values. I anticipated after the
research team reached a consensus o f interpretation, I w ould verify the interpretations by
m em ber-checking. I planned negotiations w ith the participants until consensus could be
reached that took their perspectives into account.
Ontological authenticity refers “to the extent to which individual respondents’
own emic constructions are improved, m atured, expanded, and elaborated, in that they
now possess m ore inform ation and have becom e m ore sophisticated in its use” (G uba &
Lincoln. 1989, p. 248). The nurses’ self-awareness o f being in the world could be brought
to consciousness by their participation in the study. By reflecting on the research
questions and the participants’ own practices and personal experiences, the participants
m ay experience heightened awareness o f them selves and their nursing practices
concerning w om an-centered philosophy and care o f childbearing women. The nurse
participants m ay reenter m aternity clinical practice w ith greater insight into how w om an-
centered care is im plem ented o r impeded in their practice. As care is provided in the
future, participants m ay find them selves m ore aware o f liberating or oppressive aspects
o f w om en’s experiences in childbirth. I planned to assess for the possibility o f ontological
authenticity during a follow-up m em ber-checking interview. I planned to listen for how
the nurses voiced increased awareness o f w om an-centeredness in the practice arena. I
planned to present evidence o f ontological authenticity in the final research report.
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Catalytic authenticity “m ay be defined as the extent to w hich action is stim ulated
and facilitated by the evaluation processes” (G uba & Lincoln, 1989, p. 249).
Participation in the research process prom pts som e form o f action and/or decision making
by the stakeholder. I f nurses’ self-awareness o f w om an-centered care is increased by
participation in this study, this m ay lead to participants recognizing the need to take
specific action to provide w om an-centered care. Catalytic authenticity is accom panied by
evidence o f participant em pow erm ent, know n as tactical authenticity. “Tactical
authenticity refers to the degree to which stakeholders and participants are em pow ered to
act” (G uba & Lincoln, 1989, p. 250). In follow-up conversations w ith participants I
planned to listen for individual nurses voicing the need to change nursing practices. I
realized such acclam ations must be claim ed as a personal goal o f the individual nurse. I
planned to assess for the potential for catalytic and tactical authenticity during m em ber-
checking. During m em ber-checking I intended to listen for participants’ reporting actions
taken toward im proving nursing practices for childbearing w om en, o r recom m ending
changes in nursing education and/or em ployee orientation o f future maternity nurses.
Tactical authenticity m ay be revealed through collective or individual action o f
participants to seek changes in nursing education, m aternity nursing practices o r health
care delivery that affect w om en’s experiences in childbirth.
Protection o f H um an Participants
Prior to beginning the research I planned to have the study reviewed and approved
by the G eorgia State U niversity Institutional Review Board (IRB ). I planned to conduct
the research process in a manner to protect the confidentiality o f the participants. I
planned to label audiotaped interview s with participants’ initials o r a corresponding
num ber, rather than their names. I anticipated having the audiotapes transcribed b y a
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secretary who had no personal know ledge o f the participants. I planned to change the
identity o f the participants using a pseudonym selected by the researcher prior to
circulating the transcripts for other m em bers o f the research team to read. I planned to
keep the original transcriptions and audiotapes in a locked file cabinet in my office. I
intended to release no identities o r identifying inform ation in any reports, publications, or
presentations generated from this study.
At the initial interview I planned to obtain inform ed consent by having the
participants sign a consent form approved by Georgia State U niversity Institutional
Review Board (see Appendix B). I planned to discuss details o f the consent form aHd the
research study w ith the participants prior to each participant signing the form. In the case
o f telephone interview s, I planned to m ail the form to the participant prior to the
interview and call to answ er any questions about the consent form, asking them to return
the form prior to the interview.
Summary
In this chapter I described the plan for im plementation o f this study. A b rie f
overview o f H eideggerian herm eneutics as a philosophy and research m ethod was
presented. C riteria for the selection o f research participants and the process for collection
and analysis o f research data w ere review ed (Diekelmann & Allen, 1989). Procedures to
establish trustw orthiness w ere described and the authenticity criteria related to this study
were reviewed (L incoln & Guba, 1985; Lincoln, 1990). The plan for protection o f hum an
participants w as explained.
CHAPTER IV
THE RESEA RCH PROCESS
In this chapter I describe the actual im plem entation o f the research process. I
present the methods used to recruit participants and to gather and analyze data. As these
activities are described, I also include m y perspectives concerning the interaction w ith
participants and mem bers o f the research team that influenced the research process. I
describe the use o f a reflexive journal w here I recorded personal thoughts and decisions
regarding data generation and analysis. I describe data analysis as it unfolded through
engagem ent with the text and interaction w ith the research team. Any deviation from the
research plan as described in the previous chapter is delineated. This chapter serves as an
audit trail to provide the reader w ith a m eans o f evaluating the research. According to
Lincoln and Guba (1985) the audit trail provides documentation to assist the reader in
evaluating the trustworthiness o f the research findings and further understand the context
o f the study. Authenticity o f the study is described through the actions o f the participants
and m yself (G u b a & Lincoln, 1989; Lincoln, 1990).
Participant Recruitment
A total o f nineteen nurses were recruited for this study. I solicited participants
through a variety o f avenues. Since I was a faculty member at the School o f Nursing from
which the potential participants graduated, beginning spring 1998 I started collecting
names o f graduates that might m eet study eligibility. I kept an ongoing list o f the nursing
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graduates who stated they were taking positions in m aternity nursing areas. Some
graduating seniors had jo b offers in m aternity settings by their graduation dates. I
obtained this inform ation by w ord o f m outh. Graduates openly shared their plans in
conversations during graduation-related events at the school o f nursing. O n a few
occasions I purposely asked m em bers o f a class if they knew anyone taking a m aternity
nursing position. I requested a contact telephone num ber from one graduate who had a
jo b in labor and delivery so I could reach her in the future about being in the study. F o u r
other faculty m em bers at the school o f nursing also contributed nam es to the list after
conversing w ith graduates about their w ork plans. These nursing faculty also shared
names o f students they rem em bered from past classes, since D ecem ber 1996, w ho they
believed m ay have taken positions in m aternity nursing. Faculty also offered nam es o f
graduates they observed w orking in m aternity settings where they practiced or visited for
personal reasons. Incidental social contact with graduates in the com m unity also revealed
names o f graduates w orking in m aternity nursing.
From these sources I generated a list o f tw enty potential names. I eventually
recruited fifteen participants from this original list. There were four nam es on the list I
was never able to trace to determ ine their interest or eligibility. O nly one nurse contacted
failed to follow through w ith m aking an appointm ent for an interview. She voiced a
desire to participate although she acknow ledged she was w orking extra hours at the tim e
and was very busy. A fter follow -up phone messages were left unansw ered I assum ed she
was unable to participate. I found telephone numbers from the public telephone book and
telephone inform ation in order to contact the participants that I eventually recruited from
this list o f nam es. I w as able to obtain telephone num bers for ten o f the fifteen
participants through these sources. As I began contacting and ultim ately interview ing
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these first ten, the participants would often recommend a peer that happened to be on the
list. In tw o cases when this happened I inquired and received telephone num bers from the
participants that helped m e locate other potential participants on the list. In three cases, I
w as unable to find personal addresses o r telephone num bers for potential participants on
this list, but I had knowledge o f where they worked. I contacted these three at the clinical
area during their w ork hours and briefly explained my purpose in calling. I requested
their addresses and home telephone num bers so I could call them back at hom e to talk to
them about the study. In each o f these cases the potential participants freely offered the
inform ation and seemed interested in hearing more about the study. I attem pted to lim it
the tim e o f these calls to less than three m inutes. My nam e recognition and status as a
faculty m em ber aided me in being able to m ake this type o f contact possible. The nurses
shared their telephone num bers w ith little reserve and m inim al social conversation
because o f our past student-faculty relationship.
O ver the course o f the study four other participants w ere recruited, m aking a total
o f nineteen. O ne nurse’s address was given to m e by a faculty who had w ritten a letter o f
reference for the graduate w hen she was seeking a m aternity position last year. W ith no
verbal contact beforehand, I m ailed inform ation about the study to this nurse who later
returned the signed consent form and requested a telephone interview. I also made the
decision to recruit three nurses who worked in Neonatal Intensive Care U nits (N ICU ) to
participate.
In the original design o f the study I had planned to exclude nurses who w orked
full-tim e in a N eonatal Intensive Care U nit (NICU) setting. I assum ed N IC U nurses focus
m uch tim e on the clinical care o f ill infants and thus their opportunity for potential
im plem entation o f woman-centered m aternity care principles would be limited. I w as
Reproduced with permission of the copyright owner. Further reproduction prohibited w ithout permission.
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com pelled to reexamine this assum ption by a particular NICU nurse w ho heard about the
study approxim ately a m onth before I began collecting data. This N IC U nurse
approached me personally when visiting the school o f nursing and told m e she would like
to be in the study. She insisted that learning a woman-centered approach in the m aternity
nursing course had influenced her greatly in her practice w ith m others in the NICU and in
her personal life as she recently sought a woman-centered birth experience for herself.
Her display o f strong feelings led m e to confirm her participation. I planned to conduct
her interview as a “pilot” to make a decision regarding recruitm ent o f o ther N IC U
participants. Later analysis o f the text exposed ways this N IC U nurse’s interactions and
advocacy interventions w ith m others were influenced by her values o f w om an-
centeredness. I recmited tw o other nurses from NICU settings to further understand
nurses’ experiences w ith women-centered philosophy in that specialized practice area.
Consistent w ith the original design I placed an advertisement o f the study in the
spring edition o f the school o f nursing alumni newsletter that was m ailed out to all
alumni m em bers on A pril 1, 1999. This appeared to be advantageous tim ing, since I
planned to begin the study in M ay 1 9 9 9 .1 received no contacts or inquiries as a result o f
this advertisement. However, two participants who I eventually recruited through other
means, stated they rem em bered reading the ad.
A fter I started the study I followed every lead offered, not know ing how many
participants would be needed. A fter a preliminary analysis o f twelve interview s I
recognized redundancy in the texts. Since I had already had prelim inary contact with
seven others I decided to com plete those interviews to further confirm the saturation o f
data. One o f these was the unexpected telephone interview in which the participant
mailed back the consent form w ithout any previous telephone conversation, but was
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w illing to participate. O f the six rem aining participants scheduled, two n u rses worked in
m aternity nursing settings that had not been represented by any other participants,
including roles in private prenatal care and hospital-based prenatal education. I was
curious about how these participants’ experiences influenced their perceptions o f w om an-
centered care. By completing these last seven interviews I w as able to co n firm saturation
o f data and no longer sought participants. A t the same time I had exhausted all leads for
potential participants working in m aternity nursing areas.
All participants met criteria for the study. This was validated d u rin g the initial
verbal contact w ith potential participants. There was only one out-of-state participant that
w as sent informational materials and the consent form to prior to an initial verbal contact.
H er eligibility was validated at the tim e o f the telephone interview. All o th e r participants
w ere contacted by a phone call to introduce the study and inquire o f their interest and
eligibility prior to the interview. In each case the participant voiced interest in the study. I
attem pted to be mindful o f the potential pow er I may have had over the n u rse s’ decisions
to participate. D uring this inform al conversation I related the study to m y doctoral studies
and m y interest as a maternity faculty in learning about new graduates experiences in
practice. I inform ed them I w ould be sending them additional inform ation (A ppendix A)
and consent forms (Appendix B) so they could make a decision. I did not ex p ect a firm
com m itm ent at this time and intended to leave an opening for the participants to make
their final decisions later. I recorded m y im pressions o f this initial contact in field notes
and in the reflexive journal, keeping m y self self-aware o f my com m unication w ith
perspective participants. In som e cases participants voiced excitem ent ab o u t the study
and immediately suggested that they intended to participate. I f the conversation evolved
to seeking inform ation about possible interview tim es or dates, I took the lead from the
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participant and offered to set up an appointm ent during the initial contact. I found this to
be helpful to those nurses w ho were know ledgeable o f their w ork schedules and w anted
to plan their activities. Som e nurses offered dates for m e to call them back to schedule an
appointm ent because they were aw aiting their w ork schedule for the follow ing w eek o r
m onth. A ll participants w ho scheduled an appointm ent during the initial contact w ere
encouraged to call me i f they had concerns about the study after reading th e inform ation I
w ould be m ailing to them (A ppendix A & A ppendix B).
T he nurses required flexibility in scheduling the interviews due to their w ork
schedules. Participants w orked across all tim e periods, nearly h a lf o f them w orking eight-
hour shifts and the other h a lf w orking tw elve-hour shifts on a typical w orkday. As I
began to schedule appointm ents for interview s it becam e evident that m ost participants
looked at their schedules to find a day o f f from w ork in which to schedule th e interview .
The dem ands o f their w orkday precluded alm ost all participants from m eeting with m e on
those days. I was not em ployed during the data collection tim e period betw een M ay -
A ugust 1999 and I was able to offer participants m uch freedom in selecting a date, tim e
o r place for the interview, placing few restraints on the possibilities. I scheduled betw een
tw o and three interviews each week during this time, except for three w eeks when I w as
out o f tow n. M eeting tim es usually w ere m id m orning or early afternoon. A letter
describing the research project (A ppendix A) and a copy o f the consent form (A ppendix
B) w ere sent to each participate after I initially contacted them by telephone and prior to
the interview .
Participants voiced varied reasons for interest in this study. A few m entioned they
w ould love to “help me,” identifying w ith m y role as a student com pleting a required
project. O thers talked about how learning m aternity nursing in the undergraduate course
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had profoundly affected their lives and they w anted to talk about that. O ne mentioned
w anting to “give som ething back” to the faculty and the school. Two o r three reflected on
the m aternity course being given a bad reputation by other students o r faculty w hen they
attended nursing school. They did not agree and w anted to tell their perspectives. I
listened to their com m ents and recorded such responses in m y field notes, yet I attem pted
to rem ain neutral concerning such issues so that I w ould not be condoning or leading
participants' thinking related to the research phenom enon.
Setting
All the participants in this study w ere educated in the sam e nursing program and
currently em ployed as nurses in the Southeastern U nited States. A ll the participants
w orked in urban geographical areas. The social environm ent o f the region is greatly
influenced by the patriarchal values em bedded in a com bination o f traditional Southern
culture and C atholicism . Both o f these cultures support perspectives that tie childbearing
to religious values and support w o m en ’s subservience to m ale-focused ideology - even as
it relates to how w om en are to give birth. Superiority o f m ale logic and hierarchical
relationships were evidenced in educational system s w here the nurses w ere educated and
in the m edical care environm ents in w hich they w ere em ployed. The assum ption that
authoritative know ledge o f birth rests prim arily w ith physicians and m edical
establishm ents was evident as nurses in this study described consum ers’ lack o f
aw areness o f their birth options and the attitudes o f care providers.
Each nurse graduated from the same generic baccalaureate nursing program
w here the undergraduate maternity course presented a w om an-centered approach to care.
The graduates sought em ploym ent in a m aternal-new born o r reproductive health settings
as their preferred choice for beginning their nursing careers. Seventeen o f the nineteen
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participants reported employment at acute care hospitals. D elivery rates reported at the
hospital settings varied from 600 to 7000 a year. Thirteen participants w orked at private
hospitals, w hile four worked at public facilities. Tw o nurses w orked in am bulatory care
settings. One w orked for a private physician, and one w orked at a public health clinic
setting.
All birth settings in which the participants worked advertised a fam ily-centered
philosophy o f care. T he birth settings included both labor-delivery-recovery room s and
traditional separate labor and delivery rooms. O ne hospital had a small unit w ith “one-
room ” m aternity services including a labor-delivery-recovery-postpartum (LD R P)
setting. The unit was designed for mothers w ho w anted m inim al medical intervention,
although the participant who worked at that agency reported a high epidural rate on the
unit.
V aginal and cesarean births were perform ed in these birth settings. O bstetricians
w ere the prim ary birth attendants who practice at these facilities and were identified as
being the gatekeepers to the w om en’s care and in possession o f hierarchical authority. A
m idw ife w as reported on staff at tw o settings on a limited basis, although one midwife
w as described by a nurse participant as not being a “typical” m idw ife because she
frequently used pitocin and she had a high epidural rate.
The participants in this study com m only described their w ork environm ents as
“m edically-focused.” N urse participants described rigid m edical orders that set care
protocols for routine medical intervention. A lternation in these protocols required
physician approval. W omen admitted in labor w ere com m only put to bed w ith continuous
IV and fetal m onitoring upon admission. Labor induction seem ed to be the m ost common
type o f labor situation the nurses managed on a daily basis. N urses repeatedly reported
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high labor induction rates due to patient o r doctor convenience. The birth units typically
reserved a certain num ber o f beds for daily scheduled inductions. Epidural rates at each
labor setting w ere reported by the nurses as approxim ately 95 to 99%. O ne labor and
delivery nurse reported she had never seen a woman give birth w ithout an epidural in her
one-and-a-half years o f experience. O ther nurses reported that it was a “rare” occurrence
to care for a w om an w ho planned to deliver naturally. A nurse with tw o years experience
w orking on a busy birth unit recalled caring for only four o r five m others w ho had
planned to have m inim al medical intervention.
M any participants described the inpatient clinical settings as “ fast paced,” “high
volum e,” w ith “high risk, diverse populations.” Participants cared for a w ide range o f
w om en from all socio-economic levels. Participants in private hospitals often cared for
both wealthy, privately insured women who were typically married, as w ell as the poor,
M edicaid dependent w om en in alternative family situations. A ll nurses reported ethnic
diversity in their practice settings. They reported caring for Euro-A m erican, African
Am erican. Islamic, Vietnamese and H ispanic populations in m aternity situations. C lient
ages varied from young pre-adolescents requiring m aternity services to w om en over
forty.
Three o f the postpartum care units were described as providing m other/baby units
w ith nurses caring for the couplet/family as one client. T hese units are described as being
more fam ily/w om an-centered because there is less restriction placed on the infant
interaction w ith the family and the nurse can care for the fam ily unit, w hile being aware
o f both m other and baby concerns. H ow ever freedom for infant visitation and
encouragem ent for infant breastfeeding seemed consistent w ith the atm osphere o f each
postpartum setting. The NICU units also provided liberal visitation for families.
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Generation o f Data: T he Interview Process
There w as only one participant with w hom I had m aintained contact since her
graduation and em ploym ent as a m aternity nurse. Chatting briefly prior to beginning the
interview reacquainted the other participants and me. The recent alumni new sletter
described organizational changes that were taking place at the school. N urses often
inquired about the changes and its im pact on the curriculum and faculty. A lthough
conversation about the nursing school was a rem inder o f our p ast relationship, it centered
our relationship w ithin the context o f an alum nus having com m on concerns and interests
w ith the faculty. I think this established a collegial relationship. The nurses often asked
me personal questions regarding m y status as a student o r about the status o f other faculty
at the school. W e shared inform ation concerning recent m arriages, babies, n ew homes,
hobbies or general w ork-related issues, prior to beginning the interview process.
The “getting-reacquainted” tim e period w as m eaningful as it allow ed the
participants and m e to warm up to each other in our current roles. Inform ally discussing
my research and school endeavors allowed m e opportunity to present m y self outside o f
m y traditional “teacher” role. A lthough I was a m em ber o f the faculty team w ho taught in
the classroom setting, I had only interacted w ith m any o f the participants in classroom
discussions. In the large classroom setting w here 60 to 70 students were enrolled, I did
not always have the opportunity to get know students that I did not teach in the small
clinical practice rotations. I realized I had previously taught o n ly three o f the nineteen
nurse participants in their clinical practice rotations, where a 1:8 faculty-teacher ratio w as
maintained. Therefore, in most instances, the interview represented the first prolonged
face-to-face conversation I had ever had with m any o f these nurses. This tim e period o f
chatting helped m e to become fam iliar with the participants. I tried to conduct adequate
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conversation prior to the interview; however, I did not w ant to take up m uch o f the
participants’ personal tim e on their days off. Both the participants and I w ere usually
casually dressed, appropriate for the hot sum m er days. I w ore w alking shorts o r a casual
cotton dress with sandals.
A udiotaped interview s w ere conducted in person w ith eighteen o f the participants.
The participants and I m utually agreed upon settings chosen for the personal interviews.
The participant w ho lived in a distant state requested a telephone interview and inform ed
me o f the tim e period convenient for this. Two interviews occurred at m y hom e where w e
sat at a dinette table facing a bay w indow with no one else present in the hom e. Five
nurses preferred a coffee shop in their surrounding com m unities. I arrived early at these
locations and found a table in a relatively secluded section o f the room. T he rem aining
ten invited m e to their hom es at a designated time. I traveled w ithin a ninety-m ile radius
o f m y hom e to the interview locations.
In two cases the participants had a family m em ber present for the purpose o f
babysitting for a young infant in another area o f the house. O ther participants obviously
selected a tim e period when other family members o r room m ates w ould no t be at home.
At their hom e settings I took cues from the participants about w here to conduct the
interview. The interview s usually occurred in living room o r dining room areas.
A copy o f the signed consent form was obtained prior to beginning the interview
(A ppendix B) and I answ ered any further questions concerning the study. O nce we
m utually agreed it w as tim e to begin the taped conversation concerning the study
questions I discussed the interview process with the participants. I explained I was not
looking for any specific responses, rather I was looking for their honest perspectives
based on their experiences. I invited them to tell m e w hatever they felt adequately
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answered the question. I explained that if I prodded them for m ore inform ation in any
area, I would be trying to better understand aspects o f their stories. I pointed out the red
light that indicated the recorder was on. I reminded them that the pause button on the
recorder could be applied if there was a need to stop the conversation at any tim e for a
break. This w as helpful in the home settings where occasionally a telephone call or
thunderstorm necessitated a short interruption.
The atmosphere for the interviews were kept informal, but focused on the
research topic. I proceeded w ith the open-ended questions in a sequential m anner, asking
specific details as the responses evolved. M ost participants w ere fam iliar w ith the open-
ended questions that were shared in the initial letter (Appendix A). A few participants
had written notes to rem ind them o f stories they wanted to share that addressed the
questions. The participants and I m aintained eye contact and close proxim ity to one
another throughout the interview. As expected the participants did m ost o f the talking and
I stayed engaged with the responses as I attempted to understand what w as being said.
Neither the presence o f the tape recorder nor movement o f others around us in public
places seemed to interfere w ith the interview process. There w ere m inim al pauses by
participants and I felt engaged w ith the flow o f conversation. The participants seemed
intent in describing and sharing their experiences. I attempted to listen to w hat the nurse
was saying w ithout assum ing I understood the meanings associated w ith th e story or
response. I often lost track o f tim e until hearing the 60 or 90 m inute tape click off,
indicating I needed to reverse the tape. Taped interviews lasted between 60 and 120
minutes. Often after ending the taped interview we would continue in casual conversation
about the topic. Additional com m ents made were recorded in field notes im m ediately
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afterw ards. M y impressions o f the interview, our social interactions and the context o f the
interview situation were also recorded in field notes.
W ithin five days a secretary transcribed each interview. I review ed each text
w hile listening to the tape. I listened for accuracy and altered any personal inform ation
that w ould identify the participant. A s soon as the transcripts w ere review ed, I m ailed a
copy o f the transcript w ith a thank-you letter to the participant. I invited each participant
to call m e i f they w ished to talk about the interview. I enclosed a stam ped, self-addressed
envelope for participants to return th e transcripts to m e with any corrections o r additional
com m ents they desired. In two instances I enclosed several additional questions about the
content o f the transcript and asked th e participants to clarify the inform ation. In those two
instances the participants returned a w ritten response to my additional questions. B ecause
the inform ation was clear I did not see the need to interview them ov er the telephone. I
conducted follow-up interviews by telephone in four cases regarding their perspectives
on the transcribed interview. Two participants called me and w e discussed their thoughts
about the interview, although there w ere no changes o r additions m ade. O nly tw o o f the
nineteen participants failed to return the transcript. The rem aining participants returned
the transcripts to me with m inor changes usually w ithin a few w eeks o f the interview . I
chose not to seek verbal information from the participants, when there w ere no further
questions o r concerns posed by the participant o r m y self at that tim e.
Data A nalysis
As I com pleted interviews and received the transcripts from the secretary I began
reading and analyzing the texts. I read the texts to understand the essence o f each tex t and
the m eanings o f the experiences recounted by the participants. I used the first three
transcribed texts to evaluate the effectiveness o f the open-ended questions in soliciting
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rich descriptions and personal perspectives from participants concerning w om an-centered
m aternity nursing education and their current m aternity care practices and values. I
realized participants often sum m arized their m em ories about their education in a few
broad ideas and tended to focus on the m ost positive memories. I recognized additional
questioning w as needed to solicit detailed descriptions about aspects o f the w om an-
centered course they either liked o r found problem atic, such as specific assignm ents or
the testing procedures. D uring subsequent interviews I attempted to convey m y interest in
hearing about the problem atic issues as much as the positive aspects.
I also recognized from the first three texts, that participants initially denied the
ability to practice w om an-centered care in medical environm ents. In initial conversation,
the participants com m only interpreted w om an-centered care as natural childbirth support.
From reading their stories o f practice that “stood out for them” it becam e evident the
nurses’ practices in various situations w ere frequently based upon w om an-centered
values. W hen I recognized this pattern in the text I w as able to listen for and solicit
details about the barriers nurses identified to practicing w om an-centered care, w hile at
the sam e time encouraging stories o f patient care situations where they impacted
w om en’s experiences. As nurses shared stories o f care and articulated the values that
guided their practices I hoped they too w ere realizing how w om an-centered values
im pacted their w ays o f being w ith women - even in highly medical situations.
I reread all the transcripts a second time, coding areas o f the texts that addressed
the m eaning o f w om an-centered m aternity nursing education to the nurses and the
m eaning o f their know ledge, values, and actions related to w om an-centeredness in their
current m aternity o r newborn care practices. I wrote a narrative sum m ary o f my
im pressions o f each text. A fter I com pleted this process w ith twelve interview s I returned
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to the texts for a third reading. I made a list o f significant themes that emerged for m e
from each text. I shared these initial them es with one o f the nurse researchers assisting
me with data analysis w ho had also read the texts. We talked frequently over the phone
and in personal meetings as we each discussed the em ergence o f themes. We identified
relational them es that cut across all texts and identified constitutive patterns. As w e
reached consensus on the meaning and description o f a them e, we continued to reread the
texts and continued to look for those them es in subsequent transcribed texts. I started
electronic files on each them e and transferred sam ples o f text to these files to visualize
the consistency o f the them es across texts. The nurse researcher confirm ed my b e lie f that
I was experiencing saturation o f data at this point. We both recognized hearing sim ilar
stories and meanings present in all texts. I continued scheduling additional interview s to
validate this.
Sum m er o f 1998 I had submitted an abstract to report findings o f this study in a
conference presentation at a nursing education conference at the University o f M adison-
W isconsin in mid-July, 1999. Based on the analysis o f the first twelve interviews, I
presented the prelim inary findings at this conference. I was fortunate to have three
colleagues in the audience who supported m y conclusions when they heard the
presentation o f constitutive patterns and relational them es w ith exam ples o f text. The
colleagues who heard the presentation o f the research analysis validated that the patterns
and themes I described w ere supported by the exam ples o f text I presented. This provided
me with confidence to continue the analysis process with the remaining interviews.
After a total o f sixteen interviews w ere done and the transcripts were analyzed, I
met with the nurse researchers who were assisting m e w ith data analysis to review the
prelim inary findings and initial themes and patterns that I had previously identified. The
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second nurse researcher w ho was assisting me w ith data analysis had returned after being
out-of-town the previous m onth and read the texts. In a group m eeting we discussed the
preliminary findings and validated the themes. W e reached consensus using th e
participants’ texts to support our decisions. No new patterns or them es w ere identified;
however, I struggled with w hat descriptors to use that would succinctly represent the
meaning o f the relational them es. Over the next few weeks I was able to clarify the
them es using participants’ ow n words when possible. The research com m ittee believed I
had collected sufficient raw data to substantiate the themes and needed to cease future
interviews. There were three interviews still scheduled at that tim e and I decided to keep
those appointments but not schedule anymore after those three w ere com pleted.
As I completed the initial data analysis as described earlier in this chapter, I
looked at the data through the lenses o f feminist and postmodern theory. I stro v e to
subject the explicated m eanings to additional analysis to uncover pow er relations
embedded in the text. Interpretations o f text were made using a fem inist-postm odern
critique o f the childbearing practices that were described by the study participants.
T rustworthiness
In this section I discuss the techniques I used to meet each o f the criteria for
trustworthiness as addressed by Lincoln and Guba (1985). In this study the
trustworthiness criteria included credibility, transferability, and confirm ability.
Credibility
The criterion o f credibility or truth-value o f the study is concerned w ith the extent
to which the data capture the lived experiences o f the participants (Lincoln & G uba,
1985). Establishment o f credibility ensures that the descriptions and interpretations o f the
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data are authentic representation o f the participants’ experiences learning woman-
centered m aternity nursing and practicing m aternity nursing.
C redibility was docum ented in several ways. Through this research process I kept
an audit trail as described by Lincoln and G uba (1985). I m aintained research docum ents
such as a calendar o f participant contact, audiotapes, transcripts o f the interviews, field
notes, com puter files, and a reflexive journal. Two m ethods o f data collection were used.
I interviewed the participants and recorded supporting data in the reflexive journal.
A udiotaped interview s were used to elicit a verbatim account o f the participant’s
stories and perspectives. Listening to recorded interview s allow ed me to check for
transcription accuracy and to listen to participants’ voices, to better understand the
context o f the conversation. I provided participants w ith a copy o f the transcribed text
with the opportunity o f correcting, clarifying, o r adding inform ation to fully represent
their experiences. I conducted follow-up interview s by phone or posed additional
questions on the returned transcript w hen I recognized the need for more inform ation. A ll
participants w ere encouraged to call m e if there were any concerns about the transcribed
text. Seventeen o f the participants eventually returned the transcript w ith m inor changes
or spoke w ith me in a follow -up interview.
I solicited participants who had experienced the phenom ena under study and w ho
w ere interested in telling their story. I rem ained m indful o f the previous teacher/student
relationship I had with the participants during soliciting and interviewing participants. I
attempted to set up an atm osphere o f trust w ith the participants for them to speak frankly
and honestly about their nursing education and its potential influence on them in
m aternity practice settings. To alter our previous teacher-student relationship I kept an
informal dem eanor with them in conversation and dress. I asked the participants to
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address m e by m y first name. As w e chatted prior to the interview s I displayed interest in
their life experiences and w ork-related activities on an informal basis, indicating m y
awareness o f the com plexities that come w ith being a new graduate nurse in practice.
Likewise, I w elcom ed their questions about m y graduate study and future plans. I
purposively avoided the school o f nursing as a site for the interview s. I perceived that
setting would inherently put the participant and m e into our previous roles. I offered
alternative settings and left the final decision up to the participant.
I believe a trusting relationship w ith the participants enabled them to converse
freely. On num erous occasions the participants recounted painful episodes about their
nursing education that were unrelated to their m aternity nursing education. I interpreted
this as a display o f trust that they perceived m y w illingness to hear and understand them.
I m aintained an engaged, but non-judgm ental attitude w ith w hatever information was
shared. I reflected genuine openness to listen and understand any perspective offered
related to nursing school or nursing practice issues. I used open-ended interview
questions to keep the conversation focused on the phenom ena w ithout leading participant
responses. I engaged with the research participant during the interview and accepted
w hatever responses offered as valued information to help m e understand the participant’s
experiences.
Establishing trust and openness with the participants was accomplished by
changing my self-awareness concerning m y role as nurse researcher. I viewed the
participants as nursing colleagues and m yself as a doctoral student w ho was seeking to
know m ore about new graduates’ practices after being exposed to w om an-centered
ideology in nursing school. Through informal conversations and inform ation in letters
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and consent forms. I sought to establish an openness o f inquiry that respected the
individual’s experiences and personal meanings.
The reflexive journal was m y personal record o f the research activities and served
as the second source o f data used in the study. Journal entries included m y thoughts about
the research process as it unfolded, field notes, m y recollections o f conversations w ith
participants, impressions o f interviews, and progress o f data analysis and decisions. I
w rote field notes in m y journal after each interview describing the setting, significant
events, and my thoughts, or feelings. Personal issues that impacted m y engagem ent w ith
the study were also recorded and acknowledged. Interactions with the research team w ere
recorded as data analysis proceeded.
In chapter one o f this dissertation I identified m y prejudices, past experiences, and
assum ptions related to this study concerning wom an-centered m aternity education and
m aternity nursing practices. I rem ained mindful o f m y own personal landscape as I
conducted interviews and began data analysis. I attem pted to rem ain open to the
possibility o f m ultiple perspectives about nursing school and m aternity practice
experiences within the context o f new graduate n u rses’ experiences.
M y prolonged engagement w ith this study provided further evidence o f
credibility. I studied the theoretical tenets o f feminism, w om en-centeredness, and nursing
education before beginning the study. I had taught w om an-centered m aternity nursing
four years and faced the stressors o f teaching an ideology that is incom patible w ith health
care delivery and higher education organizations. This previous know ledge attuned m e to
hear the tensions and conflicts o f practice for the m aternity nurses. I w anted to
understand the nurses’ experiences w ith these conflicts from their perspective in the
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practice arena. Through m y awareness o f these issues I posed additional questions during
conversations w ith the participants to further explicate sources o f tensions.
Peer debriefing during data analysis provided further credibility. Tw o research
team m em bers experienced in qualitative research served as neutral review ers o f the
texts. The research team m em bers confirmed m y prelim inary findings and offered critical
judgm ent as em erging themes w ere discussed. A consensus o f constitutive patterns and
relational them es across all texts w as eventually reached through our engagem ent w ith
the texts. The two research team members, a third neutral nurse researcher, and m y
faculty advisor read chapter five at its com pletion to further validate that the findings
were reflective o f the participants' rich descriptions o f experience.
M em ber checking to determ ine participants’ reactions to the stu d y findings w as
conducted. In the original plan I stated I w ould seek responses from all participants’
concerning the findings. A fter becoming more aware the com plexities o f their lives, I
realized m any did not have time to engage in a lengthy conversation w ith m e about the
findings. Therefore, I decided to call three specific participants and m eet w ith them and
share the constitutive patterns and themes. I described the meanings I derived from th e
study and engaged them in listening to my explanations w ith some detail. I instructed the
participants to listen for fam iliarity o f my explanations concerning the them es and
constitutive patterns. The three participants agreed the findings were consistent w ith th eir
experiences in education and practice and no recom m endations were offered.
Transferability
Transferability is the criterion to determ ine w hether the findings can be related to
som e other context, setting, or another population (Lincoln & Guba, 1985).
Acknow ledging the context o f the study is central to supporting transferability o f the
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findings to other circum stances. To evaluate transferability I have provided the reader
w ith adequate data that described the context o f the study.
Demographic data w hich described the research participants w ith regard to age.
ethnicity, educational background, num ber o f years in m aternity p ractice and types o f
clinical experiences are provided in chapter five. The research setting o f the study depicts
societal and organizational cultures in w hich the nurses w ork. In the reflexive jo u rn al I
recorded and described the context o f conversations and interview s w ith participants. The
extensive use o f lengthy anecdotes from the narratives in C hapter V strengthens th e
ability o f the reader to w eigh the transferability o f the study findings to other situations.
Confirm abilitv
Confirm ability criteria seek to ensure that the research procedures and data
analyses were w ithout bias. I established confirm ability through using an audit trail that
describes and justifies w hat w as done and w hy (Lincoln & G uba, 1985). T he audiotapes,
transcripts, com puter data, reflexive journal, and research team w ere tools used to
establish confirm ability. A ll decisions regarding constitutive patterns and themes
em erged from prolonged engagem ent with the text over a three-m onth period. D ata
analysis by other nurse researchers and m em ber-checking confirm ed th e probability that
findings were established from the interview data and supported dependability in th e
study conclusions.
Authenticity Criteria
A uthenticity criteria proposed by G uba and Lincoln (1989) and Lincoln (1990)
are techniques that are used to ensure that the stakeholders’ constructions o f reality have
been collected and fairly represented and to assess for actions stim ulated through the
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research study indicating involvem ent o f the stakeholders. The authenticity criteria
assessed in this study include fairness, and ontological, catalytic, and tactical authenticity.
Fairness
Fairness refers to the process w hereby as researcher I sought out and considered
m ultiple perspectives about the research phenom ena o f w om an-centered m aternity
nursing education and the lived experiences o f new graduates in m aternity practice. The
authenticity criterion o f fairness w as dem onstrated as I recruited, interviewed, and
analyzed the participants’ transcribed interviews. The audit trail serves as evidence o f
how I w ent about seeking and considering all perspectives. I recruited every m aternity
nurse participant that I was able to find who w as w illing to participate. I invited each new
graduate known to be in w orking in m aternity settings to participant in the study,
regardless o f their place o f em ploym ent o r m y m em ory o f them as a nursing student. I
valued the diverse clinical backgrounds o f the participants.
W hatever perspective the participant had about the format o f the nursing course, I
listened and asked for more details. If their m em ories o f the course were positive I used
questioning to elicit why. Likew ise, when I heard negative m em ories, I also elicited more
details to understand that perspective. This questioning is verified in the transcripts. In
two different instances participants talked in som e detail about their struggles w ith the
structure o f the course. The fact that the participants freely shared this inform ation and I
listened w ith interest and concern dem onstrates fairness. In another case a particular
participant shared h er struggle caring for w om en who are poor, A frican Am erican,
unm arried and having children. A lthough I felt discom fort in listening to her feelings, I
w as still able to refrain from being judgm ental tow ard her, and tried to elicit w hy she felt
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the way she did. In such cases I reflected on my feelings in the journal and stayed aware
o f being open to others’ realities.
I sought different points o f view regarding the usefulness o f a woman-centered
philosophy. I tried to understand participants’ perspectives on wom an-centeredness that
were different from m y own. For example, I did not believe w om an-centered nursing care
w as limited to assisting women w ith natural birth options. I believed the philosophy to
encompass much m ore nursing care strategies. However, as researcher I had to accept
this perspective and reexamine w hy participants had made this narrow association.
Ontological A uthenticity
Evidence o f ontological authenticity indicates that the research participants have
achieved a deeper understanding o f their lives and their ways o f being as a result o f
participating in the study. Ontological authenticity is evidenced through com m ents made
during participant interviews and conversations during m em ber checking activities. As I
asked participants to share episodes o f practice, they often chose stories concerning
advocacy interventions w hereby they provided care within a philosophy o f w om an-
centeredness. By sum m ative com m ents made in the texts, I think the telling o f the story
helped the participants have a clearer understanding o f how being w om an-centered
impacted the delivery o f care and m otivated them to care for w om en in a different way.
For example, a nurse who had been the most critical o f the intense focus on a wom an-
centered philosophy in the nursing course began the interview like m any others, stating
she did not practice w om an-centered care because all the w om en had epidurals and it was
not useful in hospital-based clinical practice. Yet, as the interview progressed she shared
two stories where she had given personalized care based on her acceptance o f w om en’s
differences and their rights to have the birth experience they desired, even though
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epidural anesthesia was used. She concluded. “I think I have m ore respect for w om en that
want to do som ething a little different than the norm ,” and “I guess I got that from y a ’ 11”
[the course]. Thus through her com m ents she dem onstrated her increased aw areness o f
what impact her actions have on w om en’s experiences and she v alidated her ow n use o f a
w om an-centered philosophy to im pact care.
M any participants took sim ilar paths. As the participants acknow ledged barriers
to practicing w om an-centered care, they also came to recognize h o w they still m anaged
to pay attention to certain details that made them som ew hat d ifferent from their
colleagues. They acknow ledged those differences as they talked ab o u t issues such as
other nurses’ and physicians’ aversions to women w ho com e in w ith birth plans. Through
this process the participants cam e to acknowledge how they thought differently due to
their w om an-centered values that m anifested in practice. This self-aw areness o f
difference w as so com m on that it em erged as a them e in the data analysis. By the end o f
the interviews each participant had com e to the conclusion that th ey did have
opportunities to practice w ithin their woman-centered values and they m ade a difference
in caring for wom en w hen they did so.
A nother participant shared how he struggled in nursing school w ith the m eaning
o f w om an-centered care delivered by a male caregiver. After read in g his initial transcript
he returned a sum m ary w here he clarified that he was no longer confused by the issue.
His reading o f the transcript helped clarify his philosophy o f w om an-centeredness to
focus on the w om an, regardless o f the gender o f the care provider. T hrough this study the
participant becam e m ore aware o f his ways o f being a w om an-centered nurse.
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Catalytic and Tactical A uthenticity
Catalytic authenticity is concerned w ith the extent to w hich stakeholders are
stim ulated to take action as a result o f participation in a study. Tactical authenticity
accom panies catalytic authenticity and refers to the degree o f em pow erm ent o f
stakeholders and participants stimulated b y the study (G uba & Lincoln, 1989). Not all
nurses verbalized catalytic or tactical actions. During m em ber checking I listened for
participants to report actions taken as a result o f their participation in this study. One
participant referred to a career goal to w ork in a m anagem ent position in the near future
w here m ore input into unit policies would be possible. A m ale participant voiced his
intent to pursue a transfer from the postpartum unit to the labor and delivery unit that he
had been denied before because o f his gender. This research study seem ed to have
em pow ered him to seek a nursing position w here he could m ore directly im pact the birth
experiences o f w om en. Likew ise, another participant called m e after reading the
transcription and talked for som e time about her progression in clinical practice and h er
desire to be a nurse activist. The participant voiced a desire to becom e reem erged in
professional activities.
Tw o participants were pregnant at the time o f the study and m any other
participants talked about their future plans to become pregnant. In all cases the
participants shared details o f w hat they w ere doing or w hat they planned to do to ensure
them selves a w om an-centered birth experience. Recalling th eir experiences w ith other
w om en in m aternity situations seemed to spark their aw areness o f the need to make
choices for them selves that w ould give them m ore control o f their birth experiences.
As the researcher I reflected on my feelings and actions as evidence o f the
catalytic and tactical authenticity o f this study. I felt em pow ered by reading the nurses’
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stories o f how their knowledge and acceptance o f a woman-centered view point does
affect everyday clinical practices. I realized the impact this ideology has begun to have in
the com m unity o f practice, as the new graduates are m aturing into expert nurses and
nurse leaders. K now ledge I gained through this study has stimulated me to consider what
curricular changes I w ould recom m end to strengthen the potential impact th at a woman-
centered philosophy has on nursing practice. Doubts about m y teaching methodologies
have been m inim ized and I feel challenged to continue to pursue m eaningful ways to
im part w om an-centered ideology in m ainstream nursing education and practice. I am
stim ulated to consider w hat actions w ould further explicate o r elim inate the tensions in
providing w om an-centered care in m edical environm ents and how best to evaluate these
actions.
Protection o f Human Participants
Prior to beginning this study, approval was obtained by the G eorgia State
U niversity Institutional Review B oard (IRB). As previously described, a letter explaining
the study and a copy o f the consent form was m ailed to each participant prio r to the
scheduled interview (Appendix A & A ppendix B). Before starting the interview each
participant was given an opportunity to ask m e any questions concerning the study or
consent form. A signed copy o f the consent form was obtained from the participant and
an additional copy w as left with the participant for their records.
C onfidentiality o f each p erso n ’s decision to participate and the subsequent use o f
the interview tapes and transcripts w ere explained. C onfidentiality o f each p erso n ’s
interview was assured and discussed w ith them. I informed them o f their right to review
and change anything on the transcript to accurately reflect their experiences. I stressed
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that the participant could withdraw from the study at any time. N o participant w ithdrew
from the study after the interview process began.
In order to ensure participant anonymity, the tape sent to the transcriptionist
included only the first nam e o f the participant and a pseudonym . This pseudonym w as
used on the transcript circulated to the participant and the research team m em bers. T h e
confidential secretary stated she had no personal know ledge o f nurses working in
m atem al-new bom settings. Transcripts, audiotapes, com puter files and research n o tes
were kept in a locked file in m y home and will be kept in this m anner for three years
beyond the study at w hich time they w ill be destroyed by shredding and deleting
information.
Summary
In this chapter I described the actual research process as it occurred. I explained
deviations from the original plan. I described the research participants and their practice
settings. I discussed matters related to trustworthiness and described the steps taken to
enhance trustworthiness o f this research study. I presented evidence o f actions by
participants or m yself that supported fairness, ontological, catalytic, and tactical
authenticity criteria.
CHAPTER V
FINDINGS A N D D ISC U SSIO N
In this chapter I present dem ographic inform ation and w ork-related characteristics
that describe the nurses in this study. I discuss th e findings that resulted as I entered the
“herm eneutic circle” with participants and sought to understand their experiences. I
describe the constitutive patterns and them es that em erged from this process and used
rich descriptions o f the nurses’ experiences to support m y analysis o f findings.
Description o f Participants
There w ere nineteen participants recruited for the study. The ages o f nurses w ho
participated in this study ranged from 23 to 43 years, w ith the largest num ber, 9 out o f 19.
betw een ages 25 to 29. (See Table 1).
Table 1
A ge D istribution o f Participants
Age Ranges N um ber o f Participants
20-24 3
25-29 9
30-34 4
35-39 1
40-44 2
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221
Length o f em ploym ent in m aternal-infant care areas ranged between 6 m onths
and three years. As noted in Table 2, the largest n um ber o f nurses, 11 out o f 19, had
w orked in staff nurse positions in m atem al-new bom areas between one and tw o years.
Table 2
Length o f Em ploym ent in M aternal-Newborn Practice
Length o f Em ploym ent Number o f Participants
6 M onths 2
6 M onths - 1 Year 1
1 - 2 Years 11
2 - 3 Years 5
Four nurses stated they periodically assum ed a “charge nurse” role on certain days w hile
the m ajority worked in s ta ff nurse roles providing direct patient care services. O nly one
participant reported currently being enrolled in graduate school in a M asters’ program
with a nurse practitioner focus.
Ethnic diversity o f the nurse participants closely followed the school’s reported
20% adm ission o f m inorities. This low percentage o f m inority adm issions m eant less
probability o f finding m inority nurses w ho chose to w ork in a m aternity specialty area.
Sixteen out o f nineteen participants w ere Euro-A m erican, w hile three were A frican
A m erican. Eleven participants were m arried, seven w ere single, and one was divorced.
Seventeen participants w ere female and two w ere m ale. Finding tw o m ale m aternity
nurses to recruit into the study was unexpected. T his is not a typical occurrence in this
com m unity, yet both m en stated they sought positions due to their initial interest in this
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practice area during their nursing education. All participants w ere from urban areas and
represented two states in the Southeastern United States.
Participants identified their prim ary nursing experience to be on a m atem al-
new bom (including NICU) o r a w om an’s reproductive health setting. Only two
participants reported any w ork experience in a clinical area outside o f m atem al-new bom
nursing or w om en’s health. Eighteen o f the nineteen participants w ere em ployed in
m atem al-new bom or reproductive health settings at tim e o f the study. One participant
recently transferred to a medical departm ent after w orking six m onths in labor and
delivery.
A group o f ten participants worked alm ost exclusively in a traditional labor and
delivery setting. One o f these labor and delivery nurses reported teaching prenatal
education classes part-time, w hile another reported being cross-trained to m other/baby
and working there occasionally. Tw o additional participants w orked in com m unity health
settings, one in family planning services and one in prenatal care services. Four
participants reported work experience in predom inately postpartal or m other/baby units.
All the postpartum nurses reported being cross-trained in other areas, such as traditional
nurseries, intermediate care nurseries, high-risk in-patient antepartal, o r gynecological
care areas. In a few instances the postpartum unit also adm itted high-risk antepartal
clients or women hospitalized for gynecologic disorders m aking the postpartum unit a
mixed population. Three participants worked in N ICU units at hospitals co-existing with
a high-risk labor and delivery unit and a m aternal-infant transport program.
There was difficulty in rigidly assigning nurses to a specific w ork category' due to
their mobility. Four nurses reported approxim ately equal tim e w orking in more than one
prim ary clinical site. For instance the nurse w ho worked in fam ily-planning services had
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transferred there after working one year on a traditional postpartum unit. Likew ise the
nurse who w as employed in prenatal services for a private obstetrician had worked over a
year on a labor and delivery unit. O ne o f the m other/baby nurses had transferred to that
area after w orking over a year and a half in labor and delivery. O verall, the participants
represented a vast spectrum o f m aternity-related clinical positions and their m ultiple roles
and experiences provided diverse clinical perspectives. This diversity provided
opportunity for rich descriptions o f clinical practice.
Findings
Three constitutive patterns emerged from the herm eneutical analysis o f the data:
Otherness, Being and Becoming a W om an-Centered Nurse, and Tensions in Practicing
W om an-Centered Care. The patterns and relational themes that em erged from this study
are depicted in Table 3.
I used a com bination o f m y words and the words o f the participants in nam ing the
constitutive patterns and themes. M y understanding o f the patterns and them es emerged
w ithin a circular hermeneutical m ethod o f analysis. I returned often to the transcripts o f
the interviews and the nurses’ rich descriptions o f experiences in w om an-centered
m aternity nursing education and m aternity nursing practice. I revisited perspectives in
research and theoretical literature that opened m ultiple possibilities o f m eanings. W riting
the findings in this chapter reflected my understanding o f the nurses’ experiences as I
m oved about in the hermeneutical analysis. T he w riting o f this chapter becam e the
research, as the m eanings were m ade explicit (van Manen, 1990).
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Table 3
C onstitutive Patterns and Them es
C onstitutive Patterns Them es
O therness T he m aternity course: The opening o f a
w hole other light
T he negative attitude about the course:
I d id n ’t agree w ith them
O ther nurses w ould not have done that
B eing and becom ing a woman-centered D eveloping a philosophy
nurse Putting the w hole package together
Tensions in practicing wom an-centered Tem porality: A tim e to be bom
care W om an-centered care in a m edically
focused environm ent
Relationships
I used fem inist-postm odern perspectives to critique th e narratives and situate the
stories within their historical, social, cultural, and political contexts. Pow er issues
em bedded w ithin childbearing practices were critiqued throughout using F oucault’s
theory o f power. Likew ise a fem inist-postm odern perspective helped m e look for possible
m eanings in participants’experiences and realize that no one interpretation is final or
absolutely true. Rather, the findings reported in this chapter represent one possible
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interpretation. These interpretations em erged through m y engagem ent with the texts, as a
historically and culturally situated being. The interpretation o f texts and the research
findings are subject to change with each reading o f the texts. The w riting o f this chapter
is a collage that pictures the phenom ena o f w om an-centered education and practice at this
place and tim e based o n a herm enutical “m ethod” o f data analysis. The three constitutive
patterns and their relational themes that evolved are each presented.
Constitutive Pattern: O them ess
An essence o f othem ess or difference em erged from the participants’ experiences
with w om an-centered ideology on several different levels. The notion o f w om an-
centeredness presented itse lf to the participants as encom passing values, beliefs and
actions that are out o f the ordinary and uncommon in nursing education and practice.
Participants reflected on the course and w om an-centered birth perspectives taught in the
course as “other.” T hey perceived they were “other” as com pared to th eir peers in
nursing school and colleagues in practice, who they believed did no t em brace w om an-
centered ideology. A sense o f othem ess was revealed though the n u rses’ stories o f their
experiences in nursing education and clinical practice.
Participants’ stories indicated they were com pelled to understand m ultiple w ays
o f birth outside the constructed m ale m odel o f m edicalized birth. B eing other (w om an)
was affirm ed as a positive value. D ifference was not m inim ized, rather acknow ledged
and celebrated. The nurses in this study openly claimed and appreciated the difference
they experienced in the classroom . Participants described becom ing aw are o f m ultiple
perspectives about w om en and birth through engagem ent with a num ber o f discourses
including, nursing textbooks, research studies, birth stories o f m aternity nurses,
autobiographies o f w om en, and holistic perspectives.
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Participants talked about their experiences in the w om an-centered m aternity
course as being quite different from other experiences in nursing education. W hen they
enrolled in the course, all participants w ere second sem ester Junior level students who
had com pleted three sem esters in nursing school. T heir memories o f the course focused
on their perceptions o f the differences in the course. A s one participant concluded, “ it
was m ore liberal than I guess the rest o f the schooling w as.” A lthough several
participants talked o f recognizing the sim ilarities betw een holism and w om an-
centeredness, both discourses continue to remain outside the dom inant culture o f health
care and represented difference from the status quo. Differences recognized by the
participants included the format and structure in the classroom based o n fem inist
pedagogy and the application o f a woman-centered ideology for m aternity practice.
Participants rem em bered the chaos and uncertainty they initially experienced in
the class. Participants recognized teaching strategies and expectations o f students to be
different and requiring a period o f adjustm ent, whereby they “let it flow .” They recalled
feelings o f gratitude for a new experience and felt relieved that the class was different.
The participants described unrest am ong class peers w ho they perceived, for various
reasons, had more difficulty adjusting to the course than they did. This gave them a
perception o f being “other” as com pared to many nursing peers in the course.
The m ost com m on display o f othem ess em erged through the participants’
recalling how the course presented different perspectives and view points on w om en and
childbirth. The participants told how they came to know how routine care practices and
attitudes o f caregivers greatly affected w om en’s choices and experiences surrounding
reproductive health care. Participants said they cam e into the course only thinking about
the m edical aspects o f obstetrics and the course offered another way to view w om en and
childbirth. M any recalled going through a transform ation concerning their beliefs about
w om en and childbirth, w hile others believed the course validated w hat they already knew
and they found this empowering. Participants believed the course connected holistic
beliefs they valued to the uniqueness o f women and the m aternity experience.
As the participants recalled episodes and stories o f care w here the ideology o f
wom an-centeredness was transferred to their clinical practices, the essence o f othem ess
reemerged. In recalling their struggles in being w om an-centered nurses in m edically-
focused environm ents, participants often com pared their values and caring activities with
other nurses or physicians who they believed w ould not o r did n o t provide care in the
sam e m anner as they did.
The them es for this pattern include: The M aternity C ourse: The O pening o f a
W hole O ther Light, The Negative A ttitude about the Course: I D id n ’t A gree w ith Them ,
and O ther Nurses w ould not have D one That. These them es represent m y interpretation
o f the ways the participants experienced “O them ess” as they lived through learning and
practicing wom an-centered ideology in m aternity nursing.
Theme: The M aternity Nursing Course: The O pening o f a W hole O ther Light
The participants described the m aternity nursing course as an opening for them to
experience the w orld o f nursing education and m aternity nursing from a different
perspective. The class format and content were recalled by A nita as a “ unique
experience.”
It was non-standard in that it w as not norm al lectures and note taking and
it w asn’t the medical model. It w as a totally different m odel w hich m ost
people w eren’t exposed to. I have fond m em ories because I w as open-
m inded and ju st let it flow and actually took all the advantages o f learning
a w om an-centered point o f view . I thought it w as a good, a unique
experience to have because you talk to other people from other
curriculum s and other schools and they have no idea o f w om an-centered
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care. All they know is the m edical jargon; no other choices available to a
w om an who is going to give birth.
The heart o f the course was described by the participants as the way they w ere
able to understand another perspective about wom en and birth. T his new understanding
caused the nursing students to consider w om en’s experiences as th e focal point for
learning m aternity nursing. Claire, a labor and delivery nurse, described how this woman-
centered focus redefined childbirth for her.
I found it [the course] opened a w hole other tunnel o r light for m e because
I really didn’t think o f birth in that way [wom an-centered]. Everybody
I’ve ever known has had hospital-based birth and m edical [focused
birth]... so it w as nice to leant it that w ay because I had n ev er thought o f it
that w ay and it really did - the em powerm ent o f w om en and all that - it
ju st showed m e a different view point.
C onnie a labor and delivery nurse for the past year reflected on how her
experiences in the m aternity course differed from other nursing courses in the curriculum .
She believed it was her experiences in nursing education, such as th e m aternity course,
that differentiated her education from the associate degree nurses she observed in
practice. Connie believed learning “broader issues and philosophies than ju st the sim ple
facts so you can pass boards’’ w as w hat had best prepared her for th e realities o f practice.
W e w eren’t so m uch focused on the specific facts and num bers and lab
values and that kind o f things cause I don’t know, as com pared to other
classes, I found trying to m em orize stuff like that and different drugs I
found that kind o f m eaningless because you alw ays have reference books
available to look up stu ff like that....you all were ju st trying to em phasize a
broader concept, w om an-centered care as a w hole as opposed to all the
specific little things. Not that w e didn’t cover high risk issues and
term inology that w e needed to be familiar with to function in the
hospital...you know , placenta previa and different things like that...
There were participants w ho believed being in the class represented a w ay to
validate w hat they “already knew” as w om en. They had experienced awareness o f
fem inist perspectives prior to being in the course and believed the course further
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sensitized them to w om en’s difference and childbirth options. Three participants: D onna.
Patricia, and A licia, described them selves as feminists. A licia described how the course
helped to nam e and validate her “other” knowledge as a feminist and as a woman w ho
had given birth,
.. .com ing into the course and seeing very credible, admirable, educated
women validating in the context o f the nursing curriculum w hat I believed
to be true about childbirth and maternal child nursing. ..um you gave it a
voice, you gave structure and validity to what I believed to be true and
substantiated the fact that w om en can, women inherently have a
knowledge base about how to give birth.
Patricia had never given birth, but she linked her knowledge and fem inist consciousness
to her previous learning in w om en ’s studies courses. She described the nursing course as
further validating her beliefs about w om en’s bodies and w om an-centered practices,
It was such a large eye-opening experience for me to begin thinking about

care o f w om en and th eir bodies as not having to be som ething that was
focused on sickness and solely a m edical and male environment. I think
that in both o f my courses then and the [maternity] course that I had at
nursing school that those ideas are very important for people to understand
and especially people w ho are going to be w orking in those environm ents.
That it’s not just the know ledge o f how to do things, like read a strip or
how to do a vaginal exam . It’s important to know all that, but it’s really
important to grasp the w om an-centered idea which also becomes I think
the family-centered idea that takes care o f... whole people. N ot ju s t sick
entities that are attem pting to produce a product, w hich in this case is a
baby.
The clinical learning in hospital m aternity units, prenatal, and family planning clinics that
accom panied the course becam e a part o f the students’ learning o f w om an-centered
m aternity nursing and illum inated philosophical differences in the care o f women.
Participants acknowledged that the course imm ediately impacted the w ay they view ed
patient-care situations in clinical practice. Keith demonstrated his sensitivity to the
different models o f care when he w ent into maternity clinical experiences during nursing
school.
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I enjoyed the preponderance o f a nursing model. I mean they [faculty]
often talked about the difference betw een the m edical model and the
nursing model, but you could really see it there, especially in the
experiences that we had in the clinical situations. I mean we w ent to a
doctor driven or resident driven O B clinic where it was very m uch unlike
the family planning clinic. The m edical model was much less respectful o f
the client, and in this case, w om en in particular. They weren’t asked if
procedures were okay. M ost o f the experiences I had were with male
residents or OB doctors and they w ere quiet, said m uch o f nothing - just
went in, did what they had to do, invited me in the room o f others without
even asking the patient whether that was okay. W hereas, the nurse driven
family-planning clinic experience w as much more sensitive to the woman.
The course became the bearer o f bad news and forced the nursing students to
com pare the ideology o f wom an-centeredness to the realities o f practice. As the
participants recalled becoming aware o f a woman-centered philosophy, they described
feelings o f anger, frustration, and sadness to learn that w om en were not given childbirth
choices and, in some instances, had their rights violated by the health care system. A s a
young nursing student in her early 20s, A nita described w hat it was like to enter the
w orld o f practice and leam that norms in the community o f practice were not com m only
based upon woman-centered principles. A nita’s reaction reflected that o f many
participants,
W hen I was a student and seeing these women go through the birth
process I would get angry at tim es because I w ould see what the medical
field was pushing on women. They d id n ’t give them choices. Because we
had our journal, we w ere able to w rite in our journals. I would express a
lot o f m y anger through there. So I mean even though this was a positive
experience for me, it did bring up anger because women in so m any ways,
as I could see in clinical, were literally sometimes being raped practically.
I rem em ber writing about that. This one woman [in labor] everybody had
to come in to examine her, exam ine, examine and it was atrocious. You
know here comes a fellow, here com es a resident, here comes this person.
Granted she is in a teaching hospital, but still, lets draw the line. So anger
was one o f the big em otions because I learned what the choices w ere and I
saw how many times women were not even given any choice.
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Introduction to the clinical care o f childbearing w om en and babies, as described
by these nurse participants, was experienced through a sense o f otherness in their w orld
o f nursing education and clinical experiences. The learning o f w om an-centered m aternity
nursing centered upon coming to realize that a w om an-centered nursing course and
m aternity care ideology did not represent m ainstream nursing education or m aternity care
w ithin the com m unity. W oman-centered philosophy represented a different or “other”
w ay o f addressing w om en’s concerns w hich m any participants recognized as a
fram ework for improving w om en’s birth experiences, decreasing unnecessary m edical
interventions, and supporting m ore sensitive care.
Them e: T he N egative Attitude about the Course: I D id n ’t A eree with Them
The participants acknowledged the negative and som etim e volatile reactions
am ong classm ates in being in a course w here content and process w ere based on fem inist
ideology. The participants were concerned that o th er peers did not quite “get it.” In each
case, the participant rationalized w hy they were different from their peers and could find
m eaning in the w ay the course was taught. The structure o f the course and the fem inist
philosophy w ere recalled by the participants as reasons for their peers’ unrest.
K eith believed the structure o f the course w as one issue that caused negative
attitudes since it contradicted the rigid classroom s that had characterized most
experiences in higher education and in previous nursing courses. The use o f birth stories,
journal w riting, and sharing o f personal and clinical practice experiences and
collaborative case studies were perceived as new learning experiences. A s an older
student K eith understood his peers’ concerns and recalled trying to help them understand
the possibilities in learning in a less structured way,
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M uch anxiety was felt for this non-traditional m odel [o f education].
O utright verbalization. ‘This is crazy. T h ey ’re not teaching us anything. I
m ean, how are we supposed to know w hat’s on the test.’ W e’re picked as
advanced students to com e into this school and m uch o f this is from
previous structured environments such that you have people who thrive in
that environment. So you get a whole class o f these people and you put
them in this non-traditional environm ent and they freak out. This is
nothing like they’ve had in the past. So it w as unsettling for many. B ut as
a m ore m ature and disciplined student, this w asn’t as stressful for me.
O ften through life in order to leam som ething, there’s no one to tell you
how to leam it and what page it’s going to be on and h ere’s the book you
need to read. I f you don’t get all the inform ation from one book, you get
another book, which is much like this class w as structured. I would often
say to them , ‘This is m uch more realistic. W hen you get out in life nobody
tells you how to go about getting know ledge you need to excel. So you
need to be a little more flexible and leam w h at’s in a non-structured
environm ent.’
A cknow ledgm ent o f peer discontent was also expressed by participants who
believed it w as the feminist and woman-centered ideologies that were the catalysts for
m uch negativity about the course. Alicia, who described h erself as being “older than the
average nursing student” and interested in feminist perspectives for a num ber o f years,
w as appalled by her peers’ attitudes,
I found the hostility among the m ajority o f the students remarkable and I
was surprised. Particularly the overt m anifestations o f hostility
dem onstrated by the very few, relatively few m ale m em bers o f the course.
There w ere two young men that would sit w ith their arm s crossed across
their chest and their face scow ling and they w ould sigh and they w ould
shift in their seats and they w ould roll their eyes. It w as ju st very blatant
that they were offended, trying to be disruptive and discounting and
dism issive. I felt really aggravated with them . I felt it highlighted a huge
deficit in the nursing curriculum - that w e as a student body could get to
the ju n io r tw o semester and find, regardless o f the course title, OB - that
anyone w ould be offended by the notion o f a fem inist perspective in health
care. A nd the women got really aggravated too and the conversations that
w ould happen outside the classroom were so angry and there was such an
assertion that w e’re not learning anything, this is too touchy-feely, it was
absurd. People were offended by a philosophical approach, believing
fem inism was being shoved down their throats. I found that very
disheartening that these individuals had such a dism issive air about w hat it
m eans to have woman-centered care and w hat it m eans to embrace a
philosophy that is, in a holistic sense, respective o f w om en.
Patricia also did not agree with other peers’ perspectives o f the course but she was
optim istic that the peers who seemed to resist the course would eventually benefit by
exposure to w om an-centered ideology,
I rem em ber the feeling that there were people w ho didn’t...w h o thought it
w as kind o f a jo k e , that it w asn’t, that it was too easy, that it d id n ’t make
any sense, that it w asn’t rigorous enough, that the thought, ju s t all this
em phasis on wom en-centeredness were ridiculous and out o f place in that
kind o f setting and I didn’t agree w ith that. I d id n ’t agree w ith it com ing in
because o f m y background in w om en studies, because 1 feel that this is
really, really im p ortan t.. .But I think that even i f they didn’t see it as being
im portant at the time, I think that eventually th ey would realize that it was
important, that it will have opened their mind up to things and allow them
to see things in a different way when they’re not even aw are that they’re
doing it.
Patricia seem ed to understand the resistance her peers w ent through becom ing acquainted
with fem inist perspectives. She related this to her personal experience o f becom ing
conscious o f gender oppression. Patricia recognized the turbulent process involved in
coming to accept this know ledge and applying it to life situations. She acknow ledged her
progression through fem inist awareness and believed h er peers w ould eventually think
differently as result o f having been introduced to a w om an-centered philosophy.
Theme: O ther Nurses w ould not have Done That
A sense o f “O therness” emerged as the participants related th eir stories o f practice
as registered nurses. T he participants’ senses o f otherness that characterized the
wom an/student-centered classroom eventually became a m irror im age o f the otherness
they felt as they began experiencing the clinical world through their values o f w om an-
centered care. Birth plans, which reflect a birthing w om an’s attempt to achieve som e
degree o f autonom y in the medical environment, represented a com m on point o f
divergence. T he participants who were labor and delivery nurses realized their attitudes
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about birth plans and w om en’s rights to choose options were different from o th er nurses
in practice.
Amy recognized her acceptance o f birth plans as an area that made h e r different
from many nurses she worked w ith in labor and delivery. A lthough Am y had placed
certain limitations on what she considered appropriate choices, she perceived h erself
m uch more w elcom ing o f alternative care options than other staff,
The w om an-centered thing was good. I find that I have m ore tolerance for
women w ho come in and say, T d o n ’t w ant an IV. I really d o n ’t w ant an
epidural until I ask for it. I d o n ’t w ant to be offered [the epidural].’ I find a
lot o f nurses get really frustrated and they’re like, she d o esn ’t want bla,
bla! And I ’m like, it’s h er birth experience and I guess I got that from y a ’ll
[nursing course]. It’s h er baby and it’s her w ay o f doing th in g s.. ..I th in k I
have m ore respect for w om en that want to do something a little different
from the norm , you know.
A m y shared an exam ple o f a situation that required tolerance o f a w om an’s difference
that she believed set her apart from w hat other nursing peers m ay have done in that
situation. A lthough the laboring w om an did not com e in with a birth plan, A m y
determ ined that m odesty was a prim ary concern for the woman. Procedures such as
vaginal checks, and the foley and epidural insertions were done being sensitive to the
w om an’s feelings. A m y knew the lithotom y position was the usual birth position used
and she anticipated this to be a challenge fo r the w om an, and intervened on h e r behalf,
When she w as complete her physician told m e to go ahead and put her up.
And I knew that if I put that lady up in those leg stirrups, she was going to
lose it. So I said, okay, w ell I’m going to put h er up in those little low foot
things and I kept her com pletely co v ered .. .So I put her in these and I
could tell she was starting to lose i t . . .So I put her bed back together and I
went out and told the physician. I said, I’m not putting her up. She’s going
to have to deliver in the bed. So I turned her on her left s id e .. ..she w as
much m ore com fortable on her side. I d on’t know how m any people
would have done that on the unit. I ju st d o n ’t think m any people w ould
have been com fortable w ith it. But it's her birth experience.
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Amy had never w itnessed another nurse challenge the routine use o f the lithotom y
position for vaginal birth, therefore, she believed her w illingness to do so stem m ed from
her internalized value to provide woman-centered care that m et the w om an’s needs for
birth. Amy achieved a sense o f identity in com paring h erself w ith other nurses.
Nurses in other clinical situations also reflected on th eir identities as nurses w ho
w ere som ew hat different from the status quo. H elen, who w orked on a busy m other/baby
unit, identified her difference as centering on the special attention she gave to cultural
diversity. She took special efforts to connect w ith the large population o f H ispanic
m others and fam ilies on her unit, appreciating their unique needs,
I really try and work w ith them and m ake sure they understand, cause they
seem to slip through the cracks and they need a lot. So I really try and
work w ith th em ...an d explain birth control pills, even though the doctor
said they did; patients d o n ’t always understand th e m ...W e ’ve got
translators that help us. When they w ork w ith me, th ey ’re in the room for
30 m inutes and they do it anyway! I really enjoy th a t.. .1 know a lot o f
people d o n ’t take the tim e to do it and they [families] really appreciate it
when you do.
Participants spoke about working in health care environm ents w here they
encountered s ta ff displaying attitudes about w om en’s social histories they did not agree
with. These stories centered on staff perceiving the wom en as “other,” m eaning inferior,
because o f race, socioeconom ic status, m artial status, sexual preference, o r th eir histories
o f drug abuse and reproductive activity. Keith described his experiences w orking in a
hospital alongside physicians and nurses w hose attitudes differed from his ow n,
I work in a very culturally focused m atem al-child environm ent w here we

have a very high population o f A frican-Am erican, often unwed m others,
the underserved, m any o f them on M edicaid. T here’s a couple o f doctors
in our facility that call it the free ticket. The patient had a ticket or free
ride or credit card and h e ’s talking about a M edicaid card. I don’t
co n d o n e.. .it always w orried me cause I’ve alw ays had a dilem m a that
silence condones it. A nd occasionally depending on w hich doctor it is, I
may m ake a statem ent, ‘w ell at least th ey ’re here and they have a m edical
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need’...T h ere are a couple o f peers that m ake jo k es about it....‘they think
everything ought to com e free.’ I ju st do what I’m supposed to do and take
care o f them. I f they have a need, I ju st try to fill it if I can ...N o t m any
that I w ork with are [client focused]. They w ant to pass com m ents about
the social situation o r w hether th ey ’re lesb ian .. ..unless there is some
particular elem ent that plays in to their care, it’s not a concern o f mine.
Keith rationalized that it w as his exposure to client-focused care throughout the nursing
curriculum and the strong reinforcem ent in the m aternity area that sensitized him to
accept people’s differences and be non-judgm ental in nursing care. M uch like Helen,'
Keith also recognized his difference from the staff around him , but attempted to go about
his everyday w ork caring for wom en w ithin his philosophy.
Participants talked about the m aternity course as a period o f study w here w om en’s
differences w ere acknow ledged and nursing care strategies w ere exam ined that w ould
com plem ent and reframe those differences. Postm odern fem inists Cole (1993) and
Braidotti (1991) believed such strategies represent radical fem inist reflection that
reclaim s w om en’s difference from the ideology o f subordination and hierarchy. C ole and
Bradotti believed the dom inant male view that “difference” m eans inferiority and
inequality w ith m en was debunked through radial postm odern feminism. The participants
described how the m aternity course served to affirm w om en’s differences as a positive
value with m ultiple m eanings for childbirth. The participants w ho voiced validation o f
personal know ledge displayed what Belenky, Clinchy, G oldberger, and Tarule (1986, p.
134) called “constructed know ledge.” They integrated intuitive personal know ledge with
knowledge they learned from others. R ational and em otive thought and objective and
subjective know ing were integrated.
The participants o f this study em braced the w om en-centered philosophy and the
alternative w ays o f learning. Y et, they w ere keenly aware o f resistance and rejection o f
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the course by m any o f their peers. They seemed to understand the peer resistance,
although they did not condone it. The unrest in the course was usually described as
resistance to feminism, as well as resistance to the wom an/student-centered teaching
strategies that honored the connected classroom and w om en’s w ays o f knowing
(Belenky, Clinchy, G oldberger, & Tarule, 1986). Rejection o f w om an-centeredness was
also recognized as the desire for m ore classroom focus on the dom inant discourse o f
m edicalized birth.
Lather (1991) referred to resistance as “a word for fear, dislike, hesitance most
people have about turning their lives upside down and watching everything they have
ever learned disintegrate into lies” (p. 76). Lather (1991) believed student resistance to
liberatory education requires exploration as an “ interplay between the em pow ering and
the impositional at w ork in the liberatory classroom ” (p. 76). M any participants’ stories
provided an avenue for understanding both perspectives as they recalled the process o f
becom ing empowered and described peers’ experiences with resistance.
As m aternity nurses, the participants were able to look back and reflect upon how
woman-centered learning influenced their professional values and m aternity practices.
Participants described attending to w om en’s birth options and ethnic diversity in a way
that set them apart from others. T hey described how the exposure to a w om an-centered
philosophy influenced them to practice differently, in certain situations. Their perceptions
o f being different and doing things differently from other caregivers were often attributed
to their w om an-centered perspectives on women and maternity nursing.
Greene (1995a) believes em pancipatory education that focuses on lived situations
and reflective encounters releases the imagination that makes “em pathy p ossible...give
credence to alternative realities...break with the taken-for-granted” (p. 3). As the
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participants described, the m aternity nursing course introduced m ultiple discourses and
care alternatives for birth that served as an opening for them to perceive situations
differently and to imagine doing things differently. By learning m ultiple discourses the
participants w ere open to options and possibilities for birth, w hich w ere not com m only
observ ed in practice.
The evidence o f consciousness-raising was heard as the participants described
being different from other nurses in practice. Social injustices and the effects o f dom inant
childbirth practices on w om en’s experiences w ere m ade visible to the participants. Raised
critical consciousness was evidenced by the participants’ aw areness to the diversity and
context o f situations and their w illingness to be different and practice differently in
certain situations. Greene (1978, 1988, 1995a) believes such behaviors result from an
aw akened and active learner w ho has a conscious connection to the w orld and a personal
sense o f “what ought-to-be.” Being critically conscious o f w om en’s oppressions
supported by the dom inant birth culture opened the possibilities for nursing praxis. The
intentional actions o f the participants to change a usual birth position, value a birth plan,
consider cultural context and refuse to discrim inate care based on m arginalized social
factors, were exam ples o f participants seeking freedom from dom ination for w om en in
their care. W hile their values and behaviors left the participants w ith a perception o f
being different or other, G reene (1995a) theorizes this represents a sense o f grow th
expected from an em pancipatory educational experience, where learners can “becom e
differen t.. .find their v o ice.. .and play participatory and articulate parts in a com m unity in
the m aking" (p. 132).
A feminist-postmodern analysis o f the them es w ithin the pattern, “O therness,”
illum inated the pow er o f dom inant discourse to influence nursing education and nursing
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perspectives o f care. According to Foucault’s (1977/1980) theory o f pow er, the pre
em inent authority o f the techno-scientific curriculum was displaced by com peting
discourses that questioned the m etanarratives for m edically-focused birth. B irth stories
and w om en’s know ledge and experiences were put forward for equal consideration.
As described by the participants, the openings for understanding w om an-
centeredness emerged from learning differently. C onnections to w om an-centered care
and different perspectives o f childbirth did not occur in the usual classroom founded on a
behavioral, Tylerian (1949) designed philosophy. C onnections to another perspective
cam e through a classroom engaged in fem inist pedagogy and m ultiple discourses. The
participants explained w hy they w ere different from peers w ho they believed rejected o r
felt discom fort learning the com peting discourse o f w om an-centered birth. The
participants understood there were historical, social, and cultural influences that im pacted
their w illingness to consider the com peting discourse o f w om an-centeredness, such as
age, social background, and previous learning.
Using a fem inist-postm odern lens to view the stories o f p eer resistance to the
course reveals the pow er in dom inant discourses. A ccording to the participants, the
students w ho resisted the course desired to leam in the m anner to w hich they were
accustom ed. They w anted to leam m ore about the dom inant discourse o f m edically
controlled birth, which they perceived as m ore im portant for nurses and w anted to leam
less about the com peting discourse o f w om an-centered birth.
Participants reported hearing the bad news and having th eir consciousness raised
to the m ultiple sources o f w om en’s oppressions in the health care system and in
childbearing. Som etim es this caused them pain and discom fort. A t the sam e tim e the
participants described how they were opened to and encouraged by perspectives outside
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the dom inant m edical discourse, where they learned other “options,” or different views
on childbirth. O ver time participants established a sense o f subjectivity and identity as a
w om an-centered nurse. A ccording to W eedon (1997) the transformed identity reveals the
s e lf as a non-static, post-m odern being and offers hope for changing w o m en ’s
subjectivity in m any facets o f society
The pattern, Otherness, reflected my interpretation o f the stories o f the m aternal-
new born nurses w ho participated in this study about woman-centered m aternity nursing
education and m aternity practice o f new graduates. The nurses recalled m em ories o f
em bracing the course, even though they thought it was different, and found personal
m eaning in woman-centered education. Participants believed other peers struggled with
or rejected the course because o f its differences in philosophy and structure. Likew ise,
w hen participants brought their wom an-centered values to their m aternity practices they
also perceived a sense o f “otherness,” as they attempted to practice w om an-centered care
in m edically-focused environm ents. The M aternity Course: The Opening o f a W hole
O ther Light, T he Negative A ttitude about the Course: I Didn’t Agree w ith Them , and
O ther Nurses w ould not have D one That, are the themes I used to label the experiences o f
the m aternity nurse participants as they recalled a essence o f “otherness” in their nursing
education and their practice settings.
C onstitutive Pattern: B eing and B ecom ing a W om an-Centered N urse
The participants’ journey toward em bracing and em bodying a w om an-centered
philosophy o f care for practice w as described as a process o f “being and becom ing.” The
participants articulated their philosophy o f woman-centered care as an ideal for practice
and described w hat it meant to practice as a woman-centered nurse within the context o f
the w ork environm ent. There w ere times participants clearly described “b eing” wom an-
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centered in a specific clinical situation. However, they realized jo b restraints and their
struggles as new graduates to put the whole package together m ade this an ongoing
process o f “becoming.”
The pattern o f being and becoming a woman-centered nurse was revealed by
participants through describing the process o f developing a philosophy for w om an-
centered practice. The participants articulated their philosophies o f wom an-centered care
and described how' the philosophies were em bodied in their everyday practices. The
participants’ beliefs and behaviors that com m only represented w om an-centered nursing
practices included connecting or bonding with w om en and know ing the context o f
w om en’s lives. The participants’ stories o f practice revealed that being w om an-centered
m eant connecting with women and considering the context o f th e w om an’s situation in
order to m ake a difference. The participants told stories o f providing em pathic, gender
sensitive care, and demonstrating higher levels o f involvement, su ch as advocacy and
em pow erm ent o f women that resulted from their connections w ith women and their
understanding o f w om en’s concerns.
Participants had described the maternity nursing course as a pivotal experience in
their aw areness o f woman-centeredness as an ideal for m aternity practice. Participants’
descriptions o f entering practice indicated they learned to practice woman-centered care
on a developm ental continuum. Participants’ stories indicated th e ir starting place on the
continuum o f developm ent was based on their previous professional and personal
experiences. Participants recalled their movement along the continuum o f being w om an-
centered was influenced by their struggles with transition to practice. On this continuum
participants continued to leam fine distinctions o f w om an-centered care w ithin the
context o f the work environments. The participants sought to find a place for w om an-
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centeredness in their practices and w orked to make a difference in w o m en 's care as they
adjusted to dem ands o f the w ork environm ent.
The participants’ identified how new graduate transition to practice im pacted their
progression tow ard practicing w om an-centered care. Participants’ stories o f transition to
practice described the challenges that affected their developm ent o f becom ing w om an-
centered nurses. Personal challenges included time m anagem ent, getting the medical care
correct, and adjustm ent to the medical environm ents. The participants’ stories o f practice
indicated that their developm ent o f w om an-centered nursing care was influenced by th eir
progression o f skill acquisition and clinical know ledge as new graduates in clinical
practice. The participants reflected on length o f time in practice and its im pact on th eir
abilities to be a nurse. Participants perceived m ore tim e in practice m eant m ore
confidence and skill in routine nursing care activities that enabled them to have more
tim e to attend to each w om an’s unique needs.
The them es for this pattern include: D eveloping a Philosophy and Putting the
W hole Package Together. These themes represent my interpretation o f the participants’
experiences in developing and em bodying a w om an-centered philosophy o f nursing care
w ithin the context o f new graduate transition to practice in m edically-focused
environm ents.
Them e: D eveloping a Philosophy
C onnecting and being with w om en as they lived through the health care
experience w as a common concern for the participants. Participants articulated the
im portance o f connecting w ith women and em bodied this aspect o f w om an-centered care
in their practices. The m aternity nurses in the study often spoke o f this level o f
involvem ent as “bonding,” m eaning they established a caring relationship w ith the
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woman or fam ily and were “there for them ” during the birth event. Meg, w ho w orked in a
busy labor and delivery unit for a year and a half, described what it meant to bond.
You d o n ’t bond w ith every patient, but usually you, w ith the m ajority o f
the patients you end up bonding w ith them because you spend tw elve
hours a day with them for the m ost part, you ju s t.. .you’re their family,
you’re their friend, y o u ’re their nurse, y o u ’re everything...not everything,
but you’re a big part o f their labor.
Claire, a labor and delivery nurse, described w hat it meant for her to be involved
w ith women and families. C laire’s way o f being w ith w om en and families w as to
establish a relationship and provide personal and sensitive care within that relationship,
I like to be involved w ith m y fam ilies. I don’t like to ju st pop in, pop out, -
pop in, pop out. I like to develop a relationship. T h a t’s why I wanted to be
in labor and delivery because it's a happy time, m ost o f the time. Y ou get
to be in a special part o f their liv e s.. J u s t spending tim e with them .. .and
throwing in a personal touch. Do y a ’ll need an extra blanket, do you want
me to dim the lights. A lot o f nurses leave those big fluorescent lights on
in the room and I ju st think that’s ridiculous. So I dim the lights. Leave
just the low lights on. Just offer them whatever, like straighten your
pillows, get you repositioned cause after the epidural, they’re legs d o n ’t
work w ell, so they c an ’t move around. Just little touches like that. Just not
walking in, writing dow n a blood pressure, punch in an IV and leave. I ju st
try to develop a relationship with them in that way, ju st a trust and it ju st
works out better.
Listening to and talking w ith w ere tw o common avenues the participants
identified to “connect” with wom en. Steve, w ho worked as a labor and delivery nurse
over the past two years, described w om an-centered care to m ean establishing a caring
attitude founded on m eaningful interaction w ith some degree o f intimacy. Steve often
cared for women from lower socieconom ic backgrounds w ho were young, uneducated
concerning birth, and often had less fam ily support present during labor. H e described his
philosophy and unique style o f connecting w ith women that was important to his care,
The w om an-centered m odel was about being caring as opposed to ju st

going in. Y ou’re having a baby. Y o u ’re nine centim eters. I’ll talk to you
when you get to ten. It was about explaining, doing a lot o f teaching...I'm
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interacting constantly, m y patient becomes m y friend and then based on
w here I work and the clients I had, I mean som etim es I’m a surrogate
brother, a surrogate dad, and I have a lot o f social issues that I have to deal
w ith .. .I f you approach her correctly and you show her I’m here for you
and I tell them early, look I love you. Y ou’re here and I’m here for you. I
w ork for you. I can give them that, that reassurance, regardless o f what the
nurse last night d id .. .this nurse w orks for y o u .. .1 like to be w arm and
[m ake com m ents, etc.] hey, how can I help you., .y o u ’ve got pretty hair.
Steve described loving them as m eaning “talking to them ,” “being available, being
accessible, teaching.” H e approached w om en like this to build trust and rapport that he
believed helped to decrease their anxiety. Connection w ith women w as often described
w ithin the ebb and flow o f the care situation. Sometimes on labor and delivery
connection w ith women w as described as a slow tw elve-hour opportunity or som etim es it
occurred over minutes w hen wom en were admitted in active labor o r having a preciptous
birth. Steve gave the follow ing exam ple o f a situation w here he felt he connected w ith a
woman experiencing a fast, unmedicated labor,
Fam ily m embers w eren’t there for whatever reaso n .. .1 just rode through it
w ith her...I can recall it was a case where she d id n ’t get the epidural that
m ost w ant because she was too far dilated. So it was a quick m eeting with
her. B ut you know teaching her, sitting there teaching h e r.. .breath, relax,
you can do this as she was getting ready to just lose it. saying this h u rts...I
m ean ju s t being there with her and adding a little hum or to it, cutting up. I
ju st tried to throw m y ow n little brand o f humor for that particular patient
and it worked. A nd to get her co m m en t,...‘if it w asn ’t for you I w ouldn’t
have done this’ [I replied] but o f course you would have done it.. .She
gave m e a hug and this is a person that I may have had the pleasure o f
know ing for m aybe no more than a two hour period.
Claire, a labor and delivery nurse who had been practicing a y ear and a
h a lf on a busy m edically focused unit, recalled a woman-centered birth event
where she assessed the situation and established a level o f involvement w ith the
woman, her husband, and her doula that was appropriate for the family. In this
situation C laire said her connection w ith the family meant knowing how to go
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about supporting their personal birth wishes. C laire learned connecting and “being
there” for a woman in labor included knowing w hat level o f involvem ent was
appropriate throughout the labor experience and what level o f involvem ent was
desired by the woman and her partner,
I kind o f let them [woman, husband, doula] do whatever, cause they had
prepared, they had a relationship. I w ould com e in, m ake sure they didn’t
need anything. B ut basically this couple was one that wanted quiet in the
room . TTiey ju s t w anted the husband, th e w ife and the doula. A nd so they
really didn’t w ant m e to be in there. I h ad them hook up the blood pressure
cuff. So I kind o f throughout the laboring process w ere there i f they
needed me. A nd som etim es they did. Som etim es the doula needed a break
and I would go in cause it w as pretty long from the tim e she got there at 5-
6 centimeters from the tim e she d eliv ered .. .w hen it got time for h er to
push, she was feeling the urge to push and she needed me and h er doula to
be helping her through that extrem e pressure that she was feeling. ..I was
right here supporting her, helping her breath through the contractions and
get through that urge because w e did need to w ait on the doctor at that
point. I just got her ready and ju st sat there right by the bedside breathing
w ith her, helping her get through ail that pressu re....
Participants also described connecting w ith w om en by being em pathic, using the
metaphor o f viewing each woman “as if that w ere me in their shoes.” Peggy, a
m other/baby nurse considered em pathy as a w ay o f thinking that connected her to w om en
and provided cues on how to care for wom en, especially in difficult situations such
connecting with a w om an experiencing a perinatal loss,
.. .w hat I do is I look at it as i f that was m e in that bed. How w ould I want

m y nurse to treat m e ...if som ething ever happened to me that w asn ’t the
best thing or if I had a fetal dem ise. I’d w ant a nurse to come in and sit
dow n and sit on the bed and not sit fifty feet aw ay from me. C ause I ’ll go
in and I ’ll sit, babe, move y o u ’re legs. I w ant to sit right here and talk to
you. I sit on the bed and I talk to them and bring m y self down to their
level.
Understanding the context o f w om en’s lives was revealed through the
participants’ stories as being key to developing a w om an-centered practice. The
participants’ abilities to connect or bond and plan sensitive care for w om en was further
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enhanced by know ing and understanding the context o f their clien ts’ lives. T he
participants’ stories o f practice indicated that it was the awareness o f w om en’s different
life situations that caused them to alter care regimes, individualize w om en’s care,
advocate for their unique needs, o r facilitate their em powerm ent.
Peggy, a m other-baby couplet nurse, articulated her philosophy o f w om an-
centeredness that involved understanding the context o f women through a holistic
perspective that included their cultural m eanings o f childbirth,
It m eans...w orking with w om en. I want to respect them for w o m en ...I try
to em pathize w ith them. I view them as a person, body, m ind, spirit and
also culturally.
Peggy described situations where she had embodied this philosophy by delivering care
that was m indful o f the w om an’s cultural beliefs about childbearing. The follow ing two
clinical exem plars show that Peggy practiced her W estern beliefs concerning healthy
childbirth, while trying to be respectful and mindful o f w om en’s cultural contexts,
I bought a book on it [cultural beliefs] and I bring it to w ork because

w e ’ve had conflicts...The V ietnam ese wom en, they only w ant the w arm
w ater, and I try to bring that in. They don’t w ant to breastfeed. They d o n ’t
breastfeed until they go hom e. So w e teach them as much as w e can before
they go home. T he Vietnam ese they will let you show them how to
breastfeed and how to get the baby latched on, but they w o n ’t nurse the
baby once its latched on. T h e y ’ll let them suckle and then they want to
take them o ff and due to, they tell us, the m ilk is bad. T h at’s the bad m ilk.
So we try to explain to them that the colostrum is rich in vitam ins,
m ineral, proteins.
A s a nurse I tell them [Islamic women], I realize it’s [privacy] part o f y o u r

cultural heritage and everything, but would you object to m e evaluating
and ensuring that you are doing it [breastfeeding] properly, and generally
on the whole th e y ’ll let you see m aybe once o r twice and then th at's it.
U nderstanding the context o f w om en’s lives included being aw are o f h o w the
childbearing experience, in turn, affected w om en’s lives. Connie, a labor and delivery
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nurse, believed knowing each w om an's social situation and being sensitive to the
im portance o f the childbearing experience w as essential to provide w om an-centered care.
This is an extrem ely im portant event in this fam ily’s life. Like everyday
w hen I go to w ork you have to take into consideration, this is a very
im portant part o f this p erson’s life. Yes its my jo b and I do it every day,
but you still have to keep it special for people and not treat it like’s its an
everyday occurrence. I really try to bond with them . I ask a lot o f
questions - do they have other children, are they excited....not to pry, but
ju s t to get a better idea o f where th ey ’re com ing from and what kind o f
fam ily support they have.
C onnie described a labor situation where know ing the context o f this m other’s life
situation was essential for w om an-centered care. As she cared for a teen-age m other who
w as a victim o f rape, Connie w as mindful o f the impact the experience w ould have on her
and her future relationship w ith the baby she w as keeping. C onnie described her nursing
care that centered on recognizing the unique m eaning o f this birth event in this young
w om an’s life,
The baby looked exactly like her. A nd so that’s som ething - I was like this
is w hat w e are going to focus on. I m ean she had red hair, the baby had red
hair. H e was a precious little boy and I really focused on, you know , he
looks ju s t like you. Look at him and stuff. And she cried w hen she held
h im .. .1 m ade sure I d id n ’t leave the room and go outside to chart because
they did have lots o f q u estio n s...I really worked o n m aking sure the baby
stayed w arm the whole tim e so we could bathe him right then and there.
A bsolutely m aking sure that they d id n ’t have to be separated at any point
in tim e o r anything like that. A nything that would m ake it m ore traum atic
at all.
Likew ise, participants w ho worked in NICUs found know ing the context o f a
w om an’s life w as essential to supporting the m other-baby relationship. Sheila believed
her w om an-centered philosophy m eant “this w as an experience about a fam ily and their
new' addition to a family and not ju st what you say for them to do.” She described the
im portance o f recognizing the context o f w om en’s lives to help families deal with the
crisis o f a sick baby,
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Some o f the m others don’t com e everyday and w e tend to think, well she’s
lousy. She m ay have seven other children at hom e. And if we d o n ’t ask
and d on’t have tim e to go through the chart and find out. w e’ll ju st think
she doesn’t c a re .. .B ut when you sit down and talk to her and find out she
has seven other kids at home. S he’s working tw o jobs. She calls when she
can, but she can’t alw ays physically be at the hospital.
Sheila told how she helped a m other achieve w eek-end vistation w ith her newborn by her
concern and attention to the personal context o f a m o th er’s life,
W e had a baby that I actually fell in love w ith w hose mother was from a
rural area, sixty m iles away. She worked two jo b s also. So, we hardly ever
saw her. He was such an alert, attentive little fellow and he was there six
m o n th s.. .Everybody was saying how awful sh e was. She never came.
W ell I decided to call Ronald M cDonald H ouse and find out, if she could
get two days o ff from both o f her jobs, if she could ju st stay there. W hen I
presented it to her she told me, ‘I had been calling hotels, but they w ere so
expensive in this area.’ So if som ebody w ould have ju st asked her, she
really had been looking and I guess she didn’t know who to ask about
getting assistance. W e were able to set her up w ith the Ronald M cDonald
H ouse w here she can come and go, w henever she had the chance.
Sheila connected w ith this family and understood the context o f the situation. She
decided to go beyond her expected role as the baby’s nurse to help this w om an find a w ay
to visit her baby in NICU. Sheila actively advocated on the m other’s b eh alf by finding
her a place to stay. Through her advocacy actions. Sheila demonstrated being further
along on the continuum o f developm ent as a nurse w ho embodied w om an-centered care.
She actively sought out opportunity to change the w o m an ’s and baby’s experience in the
health care system.
The context o f the clinical situation and the m aternity nursing setting sometimes
dictated the new nurses’ abilities to advocate for wom en even after they connected with
them and understood their needs. Nurses in m edically-focused labor and delivery settings
who took on the system to change even sm all aspects o f care perceived they were
undertaking certain risks. A fter working for a year and a h alf in labor and delivery
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B arbara’s w om an-centered philosophy was em bodied as being a patient advocate.
B arbara’s story o f advocacy in labor and delivery dem onstrated the m ultiple variables she
had to consider as she sought to preserve the birth environm ent for a H ispanic m other she
cared for,
I think that it’s [woman-centered philosophy] made m e a little m o re o f a

patient advocate.. .Last night this - 1 m ean this is ju st a little everyday
incident, but I had a patient who was from Honduras and had o n ly been
here ten m onths with her husband and w anted to deliver natural. A nd she
had no pain. The physician had ordered, start pitocin i f she didn’t m ake a
cervical change in two hours. And I checked her right about two hours and
she had changed two centim eters so w e d id n ’t have to do that w hich I was
- you hate to do that on som ebody natural w ho’s progressing, w h o ’s
contracting. A nd anyway, she progressed quickly, w ent to com plete. I
called the physician, he w as there. And he wanted to take her to o n e o f our
back delivery ro o m s.. .it was her first baby and he d id n ’t like to stitch in
the LD Rs. A nd the whole thing is she, especially not being from this
country, I d o n ’t think she w as really aware, it w asn’t that she had
requested this room, it w asn ’t th a t.. .but w hen som ebody.. .1 ju st know that
it was m ore o f w hat she wanted. I called him when she w as like 7-8 and
said, s h e ’s natural, she’s m oving quickly. He came to the hospital and I
got a table in the room and then he told m e that he really d id n ’t like to
stitch in the room at all because it was h er first baby, but not that
everybody who has had a baby doesn’t have to get stitches, but anyw ay, I
actually pulled him out and talked to him in the hall and h e ’s like, do you
think m aybe w e c o u ld ...I m ean he’s a doctor I feel com fortable w ith and
honestly I couldn’t have done that w ith all o f the doctors, but talked him
and offered to get him extra lights and I think that’s w hat happened. I
knew w hat the reason...th ey d o n ’t like the lights in the LD Rs and so w e
pulled in a couple o f extra lights that w e use for different things and he
was okay with it.
Barbara em bodied her wom an-centered philosophy not only by connecting w ith this
couple and appreciating the context o f this w om an’s life. She used her relationship with
the fam ily and her know ledge as the basis for providing gender and culturally sensitive
care. Barbara w as w illing to take on the system to provide a m ore hum anistic birth
setting, although her willingness was contingent on her know ledge that th e physician was
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one w ho she could confront and o ffer care alternatives w ithout fear and risk o f
intim idation.
Likewise em pow erm ent o f w om en em erged as participants described w om an-
centered care as connecting and know ing the context o f w om en’s lives as the basis for
changing w om en’s experiences. T he participants’ focus on the em pow erm ent o f w om en
em erged in situations w here the nurses had autonom y to influence women to change
things in their control. Participants’ stories o f em pow erm ent concerned helping w om en
becom e conscious o f their health care options, teaching them new inform ation, o r helping
them find their voice. D onna provided family planning counseling to teen-agers in a
public health facility and believed em pow erm ent o f w om en was key to the
im plem entation o f w om an-centered care,
.. .em powerm ent was a very im portant concept for m e because so often
you ju st don’t think about it and you don’t think that y o u ’re actually
helping som eone to self-actualize. You d o n ’t think that they could ever get
there. You ju st assum e that th e y ’ve reached their potential o r that’s all
th ey ’re going to b e ...
D onna, a nurse in her m id-tw enties, w orked at a com m unity family planning
clinic for the past year w here w om an-centered care and em pow erm ent o f w om en w as
valued. She believed it w as much easier to put em pow erm ent strategies into action here
than in the hospital m aternity setting w here she had previously w orked. She described
how she connected w ith teen-age w om en, hoping to m ake them m ore s e lf aware o f their
actions and see other possibilities,
I had a case w here this little girl, she hadn’t had sex yet, but she had oral
sex w ith like I think a whole bunch o f guys and she did that because she
w as like, you know , they forced m e to do it. O ne guy said he was going to
shoot me if I d id n ’t...ju st talking to her and saying, y o u ’re so much m ore
beautiful than that. There’s so m uch more to you than ju st having sex. Y ou
sound like you have a mind. Y ou sound like you have so m any other
things to do. She was like, y o u ’re tw enty-five? You d o n ’t have a
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boyfriend? I w anted to let her see that here are so many other things to do
besides ju st getting married and have a c h ild .. .So a lot o f it com es through
exam ple.
Likew ise Keith, a postpartum /high-risk antepartal nurse, em bodied a w om an-
centered philosophy through using em pow erm ent strategies that helped a woman find
v oice to refuse an unnecessary medical procedure. A s an in-patient antepartal client in
K eith’s care the woman had been labeled non-com pliant in collecting her urine for a
tw enty-four hour urine analysis. Two days in a row it w as reported the wom an had
violated the test by urinating in the toilet. The physician, frustrated w ith the situation,
ordered a foley catheter to be inserted. Keith talked to the woman about the situation and
found that she did not intentionally violate the test. She w as sharing a bathroom w ith
another patient and the other patient kept em ptying her specimen pan o r she would
urinate in a specim an pan, not knowing it w as her room m ates’ specim en. Keith talked to
her about the problem and offered her the option o f a bedside com m ode chair to avoid
any confusion. K eith recom m ended this to the doctor but he continued to insist a foley be
inserted,
I w ent back and told her she didn’t have to have it [foley]. It w as only
being done because o f her inability to be com pliant with the collection
procedure and that as a right, as a patient right, she didn’t have to have it i f
she d id n ’t w ant to. If she understood that w e could still get to the end in
another w ay. I said, I’m not telling you w hat to do but I’m ju st telling you
the reason they want the foley is because you’re not following the
procedure. T hat’s twice y ou’ve ruined the test and the only w ay to not
have a foley - I didn’t say don’t do it, but the only way to not have a foley
is to not m iss a drop o f urine this next time. A nd i f I ’ve got to get you a
bedside com m ode right next to your bed, m aybe that can do it. A nd she
said, yeah, let’s do that cause 1 don’t want that thing in me. T hat thing
h u rts .. .1 was kind o f putting words in her m outh, but making her
understand that she had the right to and she w asn ’t jeopardizing or
com prom ising her care and she cam e to the m ind frame, yeah, okay. And
she stood firm. W hen the doctor cam e back in to say, look I need to do
this. I m ean w e’ve got to get this test. She really responded well and said,
T d o n ’t want it, it hurts. You put it in you. I d o n ’t want it.’ She was very
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adam ant about that. No, I’m sorry I don’t want it. And so I said, I ’ve got a
bedside com m ode I can put right here. I mean I advocated for her. He
[doctor] said, ‘fine, w h atev er.'...I felt a little guilty because I bucked the
doc and I w as told by other staff, you can't just do that. Boy y ou’ll get in
trouble. B ut I felt they were not giving her all her options and she w as not
being given the knowledge that all they were tying to do was collect urine.
Keith connected w ith his patient, identified the wom an’s perspective and desires, and
worked out what he considered a m ore woman-centered solution. In this situation K e ith ’s
advocacy was insufficient alone, he needed the woman to becom e inform ed, m ake her
decision and find the voice to refuse the procedure. Keith used educational strategies an d
made her aware o f h er rights, which influenced her empowerm ent to refuse the
procedure.
An autobiographical thread emerged for the participants as they developed a
w om an-centered philosophy for practice. The participants reported extending their
w om an-centered philosophy o f m aternity nursing beyond their professional practice to
their personal lives. Participants’ knowledge o f wom an-centered care and the medical
care environm ent w ere perceived as personal knowledge that affected their self
developm ent and their abilities to help w om en in personal situations. Participants
described how they shared their knowledge o f woman-centered birth with friends and
relatives. Those w om en participants who had given birth w hile they were on the
continuum o f professional developm ent transferred their knowledge o f w om an-centered
care to them selves, integrating their schooling, nursing practice, and personal lives.
Five participants reported personal experiences w ith birth while developing their
w om an-centered philosophy o f practice as a new graduate nurse. In each situation the
participant brought her philosophy and knowledge about wom an-centered birth into her
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birth experience. A nita and Alicia w ere two o f the participants w ho reflected on their
birth experiences and described the m eaning o f w om an-centered birth in their ow n lives.
A nita reflected on her feelings o f embracing a w om an-centered philosophy for
practice that also enabled her to create her own w om an-centered birth. As a N IC U nurse
for alm ost tw o years tak in g care o f only sick babies, “bad” perinatal outcom es, and
mothers in crisis situations, Anita found the inner strength to m aintain her philosophy o f
“norm al” birth and gave birth with m inim al medical intervention,
I took on [w om an-centered philosophy] a lot for m y self - m e being a

w om an and n o t having children yet. I took a lot o f it personally and
actually for m y s e lf...
Anita believed she so ught and created a woman-centered birth. W ith her professional and
personal know ledge she found the resources that enabled her to have a “birth experience”
rather than a “m edical situation.” It w as A nita’s b elief that she avoided a labor induction
for m ild pregnancy-induced hypertension by treating h erself w ith alternative rem edies.
She took a doula w ith h e r to the hospital for labor support because she did not trust the
labor and delivery nurses to give her the support she needed. A n ita felt her birth w as
w om an-centered because she made choices as labor progressed,
I did have to have m y m em branes artificially ruptured. I w as nine

centim eters d ilated and my waters would not break. L uckily I had my
doula there, and I felt very good about discussing it w ith h e r and actually
the OB (physician) that I h a d .. .actually gave m e m ore tim e. I mean she
(physician) w as giving me the choice. I was running the show . She was
able to let m e determ ine that [choice].
A licia’s know ledge o f w om an-centered birth w as further validation to h er that her
birth was not w om an-centered. A fter w orking in labor and delivery for six m onths, Alicia
gave birth to her third child. Her cervix was six centim eters dilated when she w as
admitted to the LDR in active labor. H er partner was w ith her, bu t looking back on the
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experience, she realized she had no patient advocate am ong the hospital staff to support
her continued attem pt at a natural birth,
I was a very vulnerable person at that tim e. I asked for som e Demerol. I
asked her to call the physician and ask i f I could have som e IV o r IM
Demerol and he said he w anted to wait till he got there and he would be
there in 20 m inutes. In 30 minutes he got there and in the m eantim e he
[physician] asked that I be considered for anesthesia, w hich I signed the
consent. He cam e into the room and I asked for the D em erol. H e said
okay and anesthesia walked into the room and he said, com e on, take the
epidural. A nesthesia is here. A nd so this m an becam e that W hite male
authority figure and you know, that’s in all o f our fathers and I said,
okay. And so I w as in the bed and probably at a 30° angle and sat up. So
m y partner o f course had to leave. Everybody left, the doctor left. Here
are the strangers in the room and I sat up to get the epidural and this nurse
w ho has been a labor and delivery nurse for 22 years w as w ith me. She
w as very kind and I said, O h m y God I feel like I have to push and I
couldn’t even get that word out and I w ould push and they w ould wait [til
the contraction was over] and continue, adm inister the epidural. I laid
back and w as com plete and o f course w hat w as happening the whole time
w as that I sat up and was com plete.. .1 needed an advocate o r I needed a
nurse that had the knowledge.
A licia w as left w ith feelings o f anger and disappointm ent that becam e a part o f her
m em ory o f birth.
Participants w ho had not given birth described ways their knowledge o f woman-
centered m aternity care affected their personal developm ent in equally powerful avenues.
M eg, a young nurse in her early 20s, believed she had becom e m ore connected to herself
and better understood w om en’s concerns as a result o f her year and a h a lf experience
w orking on labor and delivery,
[Being a m aternity nurse] brings you a lot closer to yourself. You learn a
little bit about yourself every day that you w o rk ...It’s ju s t extrem ely
e m o tional...at one point in m y life I probably thought I could never
im agine m y self having children and now I c a n ’t im agine not going
through the birthing experience. You really becom e in touch w ith yourself.
Y ou really understand what being a wom an is all about. It has been a
w onderful experience and I w ouldn’t trade it for anything in the world at
all; Nothing.
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Participants com m only described themselves as being a birth advisor to friends
and relatives. Patricia shared the personal influences around her ability to help pregnant
friends and her growth as a person concerned for w om en’s issues.
O ne o f m y friends that’s pregnant has two m asters from Y ale. S he’s an

incredibly smart w om an, but she d o esn ’t have health insurance. She owns
and operates a little clothing store w ith her boyfriend and substitute
teaches. She’s been on M edicade and she didn’t realize that sh e d id n ’t
have to go to a c lin ic .. .you don’t have to see a different do cto r every
w eek. I was able to recommend h er to som eone.. .1 talk to them and
answ er their questions.
On a more personal nature Patricia, who had not given birth, believed her know ledge o f
w om an-centered m aternity care had stim ulated her concern for w om en’s issues,
..the m ore you leam about wom an-centered ideas and things like that, the
m ore important it has becom e for m e to advocate for things like that and
the m ore I have had a need to be part o f things that make a difference for
w om en.
The participants’ progressed in their developm ent o f a w om an-centered
philosophy that was em bodied in practice and in the personal. A lthough the participants
encountered challenges to being and becom ing woman-centered nurses, they found ways
to connect and understand w om en in order to make a difference in th e ir care. Based on
the context o f the situation and work environm ent, the participants w ere able to provide
gender sensitive care and advance to advocacy or em pow erm ent strategies w ithin a
philosophy o f woman-centeredness.
Theme: Putting the W hole Package Together
W hen the new graduates entered practice they described the p rocess o f attaining
the know ledge and skills they needed to becom e functional on the m aternity and newborn
specialty areas, while also trying to care for women w ithin a w om an-centered philosophy.
The participants reflected on the tensions o f learning to fulfil job expectations o f the
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institution, w hile also caring for women, new borns, or families, as they desired. Although
the participants believed they had gotten “the b asics,” and “a good foundation” in nursing
school, they articulated the need to gain additional know ledge o f high-risk pregnancies,
labor com plications, medical emergencies, and dealin g with fetal deaths after entering
practice. Gaining proficiency in skills, setting priorities, getting organized and getting
along w ith the doctors, were com m only m entioned as areas in w hich they needed
continued learning after entering practice. The participants’ stories indicated that in
practice they gradually developed the knowledge a n d skills in high risk areas and became
more proficient in basic nursing care. In going thro u g h this developm ental process,
however, the new nurses were often so overw helm ed or distracted by learning nursing
skills and routines that they were not able to focus on their developm ent in w om an-
centered care. The theme, “putting the whole p ackage together,” reflected the tensions the
participants faced as they worked to adjust to the dem ands o f clinical practice and
develop as woman-centered caregivers.
Renee, a nurse in her 40s w ith two and a h a lf years o f practice, w orked on a
com bination postpartum-surgical gynecological unit. Becom ing a w om an-centered nurse
who cared for the family meant she had to learn to set priorities and learn organizational
skills,
I think its hard for nursing school to really g iv e a floor nurse a feeling o f
what nursing is really about. I mean I had a good foundation. But gosh,
when you get out there, there’s so m any th in g s you ju st have to put
together and be responsible fo r...ju st the assessm ent process. It’s so
overwhelm ing and I’d have this checklist an d I ’d go dow n the checklist
and I’d walk out the room and go, oh my G o d , I forgot to check the
H om an’s sign again. I work with usually 7, up to 15 patients and when
you have three people on triple antibiotics a n d you’re trying to figure out
your schedule, everybody gets everything th e y need. I believe in taking
care o f the family. Hey if the dad is sleeping on the sofa and it’s not
opened up, then you want to get opened up. You want to get the sheets, the
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pillow cases and the blankets. W hen I leave the room I like everything
com plete so I can go on to the next person.. .1 ju st know as a nurse that the
longer I’m practicing th e better you get at it and you start p u ttin g the
w hole package together.
It w as necessary for Renee to learn the nursing functions expected b y the institution and
to perform them within a certain tim efram e. She had to becom e proficient in those skills
as her top priority, w hile m aking space for her w om an-centered care values.
M eg, a labor and delivery nurse on a busy, high volum e unit, reflected on h er year
and a h a lf o f experience. She described the unit she worked on as “ so m edically oriented,
it is hard to put that w om an-centered care into play.” M eg recognized w om an-centered
birth care w hen she had an opportunity to care for a w om an w hose phy sician gave her
options. Unfortunately, M eg felt the usual nursing responsibilities included medical
interventions and routine care protocols that she had to becom e proficient with in order to
w ork there. The possibilities for wom an-centered care were only beginning to em erge as
a concern for her,
In the beginning it w asn ’t as hard [having w om an-centered know ledge] as

it is now. In the beginning y o u ’re ju st learning. Y ou’re trying to g et a feel
o f everything th a t’s going on in the hospital and with such a large patient
population and w ith such a large doctor population, y o u ’re ju s t kind o f
like okay, whatever. W hatever happens is the w ay it’s supposed to be then
you kind o f get com fortable w ith what y ou’re doing and then you realize
that this is not fair to the patients. They’re not getting the things th at they
w ant. So I have begun to stand up to the doctors m ore that I had in the
beginning.
M eg 's developm ent over the past year and a half reflected her ability to becom e
assim ilated into the culture by learning the routine care procedures. N o w that she had
becom e proficient in them, she could reflect on the meaning o f the m edical care to her
practice and the care o f women. M eg described her self-awareness em erging.
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Learning to work w ith physicians in the medical care environm ents was another
area that influenced participants’ transition to practice and their developm ent o f being
w om an-centered nurses. M eg’s courage to confront doctors was another area o f
developm ent that was necessary for her to leam . M eg’s education on confronting doctors
stem m ed from this experience she recalled,
I had a patient that had been there for two nights. She had been on cytotec
and pitocin. She was still one centim eter, sky high and having ju s t awful
heart tones. I called the doctor and told him I ’m not com fortable doing
this. I told him I turned o ff the pitocin and w as going to fax him the
p atient’s strip. So I faxed it to h im .. .everybody on the unit had agreed the
heart tones were not good. A fter contractions the heart tones w ould go
dow n into the 60s for a couple o f m inutes and com e back up. H e called me
back and said absolutely, positively, without a doubt those are not
lates,..tum the pitocin back on. I said, well, I’m sorry. I do not feel
com fortable. If you w ant the pitocin back on I w ould feel better if you
cam e and turned it back on yourself. I said m y license is on the line and I
d o n ’t feel com fortable doing this. H e said, w ell, I d o n ’t care about your
license. Two hours later she [patient] ended up being a C-section. W e have
a very good nurse/physician relationship n o w ...H e knows that w hen I call
him I’m not whistling D ixie....
M eg described this incident as an example o f what she w ent through as a new graduate to
prove h erself to the doctors. This proving period was considered part o f her initiation and
acceptance as a nurse on the unit. M eg’s developm ent as a w om an-centered nurse w as
ham pered by her attention focused on medical care and pleasing the large group o f
private obstetricians, since this is what was valued on h er labor and delivery unit.
T he participants related their “w ar stories’’ in practice where they often felt ill-
prepared at the tim e to handle the situation. These stories included cases such as an
em ergency seizure related to pregnancy-induced hypertension, identifying a woman
hem orrhaging from a placenta accreta, recognizing respiratory arrest due to a m isplaced
epidural, and w itnessing a fetal demise. In these difficult situations the participants
described their role with other m embers o f the health care team in delivering appropriate
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and tim ely care. These scary situations left participants feeling they needed more
know ledge about medical problems, em ergencies, and dealing with perinatal death than
they learned in nursing school. The participants recognized over their transition period
they som ehow learned em ergency m anagem ent and attained the knowledge that m ay
have been lacking when they first entered practice.
Peggy’s story o f learning to care fo r a postpartal m other grieving the loss o f her
term baby described the essence o f what th e new graduates com m only experienced w hen
they encountered situations that initially overw helm ed them . Even though Peggy denied
being prepared from nursing school to deal w ith perinatal loss, through experience she
cam e to learn appropriate counseling skills w ith grieving mothers,
O ne o f the things that I think needs to be taught m ore in school is the -

you do teach about bereavement and stillbom s and things like that - but its
not som ething you see. And for m e, it was hard m y first infant that I lost
and they bring the baby over, you get the mom and she’s a fetal dem ise
and you go in and you ju st don’t know what to s a y ... I don’t say much. I
tell the w om an that I’m real sorry and that I ’m there for her. But I found
that I w asn’t prepared for that. It w as really hard because she ju s t cried
and cried and cried and nothing you did and I m ean I sat in the room and
w e cried together because I didn’t know what to do for her. I told her I’m
here if you need me. I’ll liste n ....if it takes a h a lf an hour, w e’ll ju s t sit
there - let them verbalize about how they feel about the lo ss...th ey want to
know w hy and I have to explain to them I can ’t give you the answ er to the
w h y ... A nd that was one thing that I ju st didn’t feel ready for leaving
school. Also seeing a dead infant ju s t totally blow s you aw ay ....
The following scenario described how P eg g y ’s developm ent as a wom an-centered nurse
caring for grieving women was aided by both her cognitive knowledge and practical
experience with the bereavem ent process. Peggy verbalized being unprepared with the
skills o f bereavem ent counseling, but her descriptions o f w om an-centered actions
indicated she connected w ith the woman and som ehow learned the art o f involvement
that she felt w as m eaningful to the woman. This story dem onstrated how Peggy’s first
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encounter with the bereaved m other was not quite right, but she corrected her mistakes
and eventually made a trem endous difference in the w om an’s experience.
.. .nobody told me, it was a shock. N obody told m e the [dead] baby is in
the isolette. I was going into the room ju st to help the patient to get up to
go to the bathroom. W ell when I w alked in her room here was this baby, I
m ean perfectly still, not breathing in this isolette w ith all the fam ily
around and I walked in and I didn’t know . So th e re ’s apparently very
much shock written on m y face..I assisted her to the bathroom. G ot her
back to bed. I bet you I m ust have said tw o w ords to her. W e did peri care.
Did you need anything for pain? O r anything else I can get you? A nd
th at’s all I said and I w alked out the room and as I shut the door I busted
into te ars.. .1 went [back] in after aw hile and talked to her [the m other] and
I apologized to her. I said, if I looked very startled w hen I came in before I
said, I ju st didn’t realize that you still had your baby w ith you. She kept
the baby and together w e went up to the isolette cause she was real
reluctant.. .the baby w as next to her bed but she had never really touched
and held the baby and I asked her did she hold th e baby and she told m e
no. I asked her do you w ant me to go w ith you and w e’ll hold the baby
together and you can touch and feel, and she said yes. So w e touched and
felt the baby and eventually took the baby out o f the isolette. Sat in her
room. H er mom was there, her grandm other and boyfriend.. .You know ,
we had a good rapport. She viewed m e as more than ju s t a nurse w ho ju st
cam e in and rubbed her fundus and checked h er bleeding. It m eant that, to
me I think she realized how much it affected m e as it affected her. That I
really did care about h er emotionally. That she did lose a child and that I
really wanted to help h er and make h er feel better. I ju s t couldn’t, I w asn ’t
ju st on an automatic pilot, going in and doing the things that you have to
d o .. .she was there for tw o days and I had her for both days after that and
w ound up that she w ould call me by name. She w o u ld n ’t ju st say, w hen
she’d call she’d say please send Peggy to her room . W ouldn’t you please
send my nurse.
Peggy learned how to be a wom an-centered nurse in the context o f offering g rie f support
to a mother. W hat Peggy had still needed to leam about this could not be know n through
“textbook” knowledge, she needed to experience the situation in the context o f practice.
As a fem inist Patricia w anted very m uch to practice w om an-centered care but she
realized getting the medical information correct was a necessary concern. Patricia who
had worked only about a year on a labor and delivery unit, still recognized the need to get
the “m edical” learning behind h er so she could focus m ore on attending to the nuances o f
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w om an-centered care in the environment- She had recently encountered an unexpected
experience o f newborn m econium staining at birth. She felt her lack o f attention to the
proxim ity o f the suction equipm ent prior to the birth was an exam ple o f h e r still needing
to “put it all together” that stood out for her,
W ell I’d like to get the suction but it w as over at the head o f the bed and
the baby ju st didn’t w ant to wait, it ju st delivered. It w asn ’t one o f those
that w as w illing to sit there with its head out for a m inute w hile w e hooked
up to suction, which w ould have been nice. Then w e could have aspirated
the m econium out but it d id n ’t do th at and suction equipm ent w as ju s t too
far aw ay...
A lthough this situation was not optim al, it represented a com m on concern for a nurse
w ho assists birth attendants. A nticipating w hat equipm ent w as needed and having it ready
for im m ediate use was a goal Patricia still aspired to achieve. Patricia’s goo d m em ories
o f this situation w ere that she responded im m ediately and calm ly to the situation,
assisting the health care team care for the baby. She felt her calm dem eanor during such a
potential crisis helped her care for both the baby and the parents. Patricia described her
self-developm ent as a w om an-centered nurse in need o f balance,
That I w ould be able to take care o f the w hole experience, both the
medical aspects as well as the more holistic aspect o f w hat the w om an and
her fam ily want to have from the experience. That I’m able to help them
incorporate whatever m eaning they w ant to have from it into the
experience. At the same time, giving them medically correct care A nd
that’s the thing, I don’t think I’m quite there yet cause, like I said, I ’m ju st
getting com fortable and I still have a long way to go I think before I ’m
really secure in what I’m doing and that the more secure that I am w ith
anticipating the em ergencies and all the things that can happen an d the
disasters - the more capable I will be at incorporating everything into the
experience. Hopefully.
A lthough Patricia was hopeful that m ore nursing experience w ould benefit her
ability to be a w om an-centered nurse, she w as also fearful that she w ould get too close to
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these m edical routines o f practice and she w ould lose her attention to w om an-centered
care,
T here’s always this fear that I will som ehow be, that I will ju st get so
used to doing it that way [m edically-focused], that that’s going to end up
being w hat I do in spite o f the fact that I d o n ’t believe it should be done
that w a y .. .that som ehow you sort o f get co-opted by w hatever
environm ent you’re in and you becom e like it.
As the nurse participants told o f being exposed to prim arily m edical-focused
norm al birth and high risk care, they were aware the possibility existed that their
philosophy o f w om an-centered care could be influenced by the m edical environm ents.
On a daily basis the participants experienced high risk medical situations w hile w orking
in the larger, referral hospitals. Claire w ho had w orked close to two years on a labor and
delivery unit spoke o f this struggle to keep her philosophy on the norm alcy o f birth w hen
she saw so m any high risk situations,
I ’ve learned that everybody has a different philosophy and th e longer I

w ork here, the m ore m y philosophy changes. Like I’m really starting to be
m ore o f a medical person now, the m ore em ergencies I see, the m ore I’m
leaning towards that. The more the w om an’s rolled in from adm itting and
sh e ’s leaving a pool o f blood all down the hallway. She’s having a
com plete abruption and our team works so w ell together. O ne person’s
starting an IV, the other one is strapping on the monitor. The other one
getting her prepped....
The participants’ continuum o f developm ent toward being and becom ing wom an-
centered was influenced by the medical environm ents in which they w orked. A lthough
the participants’ acknow ledged the norm alcy o f birth in their philosophies, m uch o f their
nursing care focused upon using wom an-centered approaches in a traditional, medical
model o f obstetrical management. The participants recalled routinely taking care o f
women experiencing medically-focused labor inductions but they also recalled being able
to sw itch gears and take care o f natural childbirth situations when called upon.
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Participants w orking in labor and delivery areas dem onstrated the ability to connect with
w om en and deal with the context o f the client in w hatever situation they found
them selves.
Connie, a labor and delivery nurse described her awareness o f the high-risk
philosophy that penetrated the unit she worked on, but somehow she had been able to
retain her personal philosophy o f birth over the past two years she worked there,
We d o n ’t need to think o f it like the rest o f nursing you know where

y ou’re trying to fix a problem. They [other nurses] treat it like
everybody’s high risk and something is going to go w rong.. .this is a
norm al process and focusing m ore o f w hat the w om an w ould specifically
w ant, who she wants around her, usually you have better outcom es...
As the participants reflected on their progression in clinical expertise they
reflected on the continued developm ent they obtained in woman-centeredness after they
left nursing school and entered the hospital and unit orientations. No participants reported
w om an-centered birth options or care protocols review ed as part o f their orientation to
hospital care. Barbara articulated this,
I think if you w ent straight into a jo b w ithout ever having that background
[in w om an-centered care], then you probably w ouldn’t think o f any o f it
like that because it’s very different. It d oesn’t mean that you can ’t
incorporate it [woman-centered care] in there but I think if you didn’t have
that background at all it probably w ouldn’t be there.
Likew ise A m y stated.
W ell, I think that the things I did n ’t leam in school and learned in practice
can be learned in practice, whereas your w om an-centered nursing, you’ll
never leam that...except in school.
The participants described learning woman-centered care in nursing school as an
ideal for practice. W hen entering practice the participants came to know the culture o f
care was not inherently woman-centered. The realities o f practice brought with it the
com plexities o f the work environment in m aternity and newborn acute care settings.
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Participants prioritized w hat skills and know ledge w ere essential to their practices and
entered a continuum o f developm ent. W ithin this continuum o f developm ent, the
participants learned w here their philosophy o f w om an-centered care fit in. W ithin this
developm ental process, the participants described their efforts to m ake a difference in the
individual care o f w om en through em bodim ent o f a w om an-centered philosophy o f
practice that was acceptable in the culture o f the w ork environment.
Experiencing the reality o f practice w ithin a philosophy o f w om an-centeredness
happened as a process o r continuum o f being and becom ing for the participants.
According to philosopher, Alfred W hitehead (1929/1978) "every 'being' is a potential for
a 'becom ing'. The actual w orld is the ‘objective content’ o f each new creation” (p. 65).
The reality o f living through new graduate transition to practice w ithin a p hilosophy o f
w om an-centeredness w as a process w hereby “all things flow.” The participants
articulated their philosophies o f w om an-centered care and described the m eaning o f
being woman-centered in practice situations. Participants recalled actual w orld
experiences and the em otions, feelings, and m eanings that accom panied the experiences.
Instances o f “being-there” as w om an-centered nurses m eant they developed a trusting,
connected relationship w ith women that opened the way to providing more
individualized, gender sensitive care that set up possibilities for advocacy and
em powerm ent. The participants believed the w om an-centered practices m ade a p ositive
difference in w om en’s experiences. This sense o f reality that there were instances o f
being woman-centered served as the impetus toward imagining future possibilities for
wom an-centeredness.
The participants’ developm ent in w om an-centered care was interw oven into their
experiences o f learning th e health care delivery system , institutionalized nursing, and the
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rules o f practice. The participants learned under w hat circum stances they could m ake
nursing care decisions based on their w om an-centered philosophy, such as connecting to
a grieving m other in a sensitive, caring manner. Participants also learned when w om an-
centered care practices required approval by others with more authority than they had,
such as w hether or not to insert a Foley catheter for a urine test. As participants learned
the contextual nature o f the work environm ent they cam e to know under what
circum stances they could safely challenge the system. They learned w hich doctors could
be approached and how to go about discussing alternative care options w ith them. They
came to leam that the rules o f practice could be negotiated.
O nly through daily experiential learning did the nurses com e to understand how to
“put it all together.” T he participants described their challenges to being o r becoming
w om an-centered w ithin the com plexity o f clinical practice. The experiences described by
the participants were consistent with the developm ent o f clinical judgem ent and nursing
expertise described by the research studies o f B enner (1984) and Benner, Tanner, and
Chesla (1996). These studies illum inated experiential learning as being key to progressive
attainm ent o f clinical judgm en t and nursing expertise. These qualitative studies described
the developm ent o f clinical expertise in critical care nurses characterized by five stages o f
practice. T he stages included novice, advanced beginner, competent, proficient, and
expert. B enner et al. (1996) qualitatively described the stages o f developm ent around
nurses’ abilities to conduct engaged reasoning, make clinical judgem ents, and become
involved w ith patients.
T he participants’ descriptions o f practice and their nursing concerns were
consistent w ith many aspects o f what B enner et al. (1996) described as the com petent and
proficiency stages. A ccording to B enner et al. (1996), the com petency stage corresponds
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with at least one and a h a lf years o f clinical experience and the proficiency stage begins
around year three. Benner et al., were clear, however, that change in practice, not passage
o f time, was the defining characteristic that reflected the benefit o f experiential learning.
The maternity nurse participants in this study recognized the importance o f experiential
learning in their developm ent o f nursing know ledge and their abilities to practice w om an-
centered care. T heir stories o f practice w here told within a tone o f concern for how o r
w hat they learned in clinical situations. T he false starts, failures, challenges, and trium phs
were indicators that they w ere on a continuum o f developm ent and wanted to m aster the
w orld o f practice in order to provide b etter care to w om en and their families.
Consistent with the com petency stage o f developm ent, the participants learned the
likely course o f events in a typical m aternity nursing situation. Based on this know ledge
the participants began to anticipate w hat nursing care was needed in the future. Planning
for and anticipating patient needs for the expected and unexpected occurrences w ere
important. By learning the routine course, the participants w ere able to im agine other
possibilities o f care. The participants distinguished between standardized and
individualized care and tried to reconcile how to negotiate both. The participant who told
o f knowing a certain doctor liked the “back delivery room ” because o f the lights
anticipated this as being problem atic and negotiated another possibility. The participants
described being concerned about the p atien t’s future, about w hat might happen, and how
nursing care can impact future possibilities. Nurses in this study dem onstrated as sense o f
agency or concern for making decisions and offering solutions that would be right for the
individual woman.
A ccording to Benner et al. (1996), o f upmost im portance to the developm ent o f
expertise in nursing care is the nurses’ ability to becom e engaged with the clinical
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situation and establish a sense o f involvement with patients. R easoning and clinical
judgm ent must include contextual awareness and perception, which com es through being
present in the situation and taking in all perceptual cues. Contextual perception is
necessary for the nurse to read a situation and immediately understand the relevance o f
changes in clinical situations. B eing attuned to the individual m eanings o f health and
illness is also necessary for the nurse to becom e an expert clinician. In this study the
participants described behavior o f patient involvem ent that corresponded w ith B enner et
a l.’s (1996) categories o f com petency and proficiency.
Participants in this study were acutely attuned to what was th e appropriate level o f
involvement required in clinical situations. Involvem ent with w om en and their intim ate
and significant others was identified as a com m on practice in the developm ent o f a
w om an-centered practice. Participants realized they could not im plem ent w om an-
centered care w ithout connecting with and understanding the context o f the w o m an ’s life.
“K now ing the patient" to these participants, m eant knowing w hat the childbirth
experience meant w ithin the context o f the w om an’s life, including h e r family.
Research by Tanner, Benner, Chesla, and Gordon (1993) illum inated the m eaning
o f “know ing the patient" (p. 275) as a phenomenon central to nurses’ practices. To nurses
in Tanner et al.’s (1993) study, knowing the patient meant “an involved, rather than
detached understanding o f the patient’s situation and the patient’s responses, and
understanding that is directly apprehended" (p. 275). Knowing the patient was found
central to nurses making clinical judgm ents and being able to advocate for individual
needs. Tanner et al. recognized the challenge to nurses learning the appropriate level o f
involvem ent in different situations. The social and cultural contexts o f care situations
require nurses to leam the skill o f involvement through experience in clinical practice.
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Learning the appropriate level o f involvem ent w ith women becam e the heart o f
m aternity nursing practice for these nurse participants. The participants’ levels o f
involvem ent w ere som etim es dependent on the expressed needs o f the w om an. Som e
w om en desired to labor w ith only her husband and doula, w hile others needed the nurse
to sit dow n and be with them. In other instances the nurse verbalized having to use trial
and error to determ ine w hat level o f involvem ent w as appropriate, especially in difficult
situations such as perinatal loss. As m aternity nurses, the participants in this study
dem onstrated that their involvem ent w ith w om en and fam ilies progressed at a faster pace
than it did for the critical care nurses described by B enner et al. (1996). The m ajority o f
participants had only one and a h a lf years o f experience, yet their stories o f patient and
fam ily involvem ent exceeded what Benner described for the com petent stage and m o re
resem bled the proficiency stage o f practice. Involvem ent w ith women and fam ilies w as
m ore readily integrated into the routine practices o f m atem ity-new bom nurses, as
com pared to B enner et a l.’s (1996) study o f critical care nurses. The participants’ sense o f
involvem ent as m aternity nurses was reflected by their practices o f concern and advocacy
and b y the language used to describe their relationships w ith women. The participants
often described their involvem ent with w om en as “bonding,” comparing it to the intensity
o f the m atem al-new bom relationship.
A utobiographical accounts emerged from p articipants’ stories linking their
education and practice in woman-centered m aternity nursing to their personal birth
experiences or their personal developm ent. Pinar (1994) theorized that curriculum w as
experienced w ithin the person’s life history. The p articipants’ education in w om an-
centered m aternity nursing occurred within their personal life histories and im pacted th eir
lives. T heir experiences in woman-centered m aternity nursing education w ere not
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confined to the boundary o f professional nursing. Learning a w om an-centered
perspective on health care and childbirth raised consciousness o f the participants that
extended to the personal. The course put them on a “path o f life” (Sum ara, 1996, p. 174)
that im pacted their experiences in schooling, their future nursing practice, and their
personal perspectives on birth. The participants described sharing those perspectives w ith
friends by offering advice and guidance. The participants w ho had given birth did so
w ithin the m eanings o f a w om an-centered philosophy.
From a feminist postm odern perspective, there w ere m any pow er issues
em bedded w ithin the participants’ descriptions o f practice. Pow er that w orked to control
nursing practices and w om en’s experiences was made visible through F oucault’s
(1975/1977) notions o f biopow er and the disciplinary techniques associated with
surveillance and norm alization o f behavior. A uthoritative knowledge in childbirth issues
centered on scientific m edical know ledge, not on the know ledge o f w om en o r nurses.
D om inant m edical discourse on childbirth becom e the “truth” and the prim ary source o f
know ledge to set childbirth standards. The pow er o f this discourse controlled the birth
event and the nurses were expected to conform care based o n medical discourse. For
exam ple, the medical discourse set specific tim e periods for cervical dilatation w hich
forced nurses and the wom an to conform to care protocols, such as pitocin augm entation,
w hen the w om an’s body did not meet the standard. The m edical discourse becam e the
disciplinary pow er by w hich the laboring w om an became a docile body.
The hospital institution used disciplinary techniques to control nursing practices
and support the notion o f biopow er. This w as evident through the participants’ attention
to perfecting tim e m anagem ent and organizational skills as a prerequisite to becom ing
functional in practice settings. Tim e and rhythm served as a disciplinary techniques that
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controlled nursing practice routines. N ursing practices were designed to maintain a high
degree o f surveillance over the women, their bodies, and their behaviors. The nurses
described behaviors resembling the “panopticon” w atchtow er, keeping surveillance over
w om en’s labor and breastfeeding progress (Foucault, 1975/1977). A ny deviations from
the norm alized behaviors set up by medical discourse w ere reported. The nurse collected
data and entered it in the patient’s record so that other authoritative experts could use it.
The participants’ stories indicated there was alw ays som e sense o f danger to the nurse
who tried to address issues o f biopower, surveillance, and norm alization and shift m ore
pow er, decision-m aking, and privacy to the patient.
The participants’ descriptions o f applying w om an-centered philosophy
represented som e resistance to the pow er relationship set up in traditional hospital
environm ents. Their involvement with wom en was, in som e w ays, an attem pt to decenter
the expert, authoritative nature o f traditional nursing. The participants w ere centered on
know ing the w om an for the explicit purpose o f establishing trust and a comfort zone
w hereby the w om an’s needs could be better served and not necessarily to keep w om en
com pliant with the medical regime. The know ledge gained about w om en was viewed by
the participants as the w ay they came to know the w om an’s situation and determine
personal needs or desires. The manner in which the participants in the study used
personal inform ation about women and kept surveillance over them was offset by a
philosophy o f practice that respected women. Participants voiced sensitivity in know ing
personal inform ation and in using the inform ation to care for w om en. The act o f
surveillance, such as with monitoring breastfeeding, was approached w ith sensitivity to
cultural beliefs. The participants’ stories o f connection with w om en also served to
illum inate that not all women experience pregnancy and childbirth as necessarily happy
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occasions. The participants demonstrated an understanding o f that. G iving birth as a
result o f rape, experiencing pregnancy loss, or the crisis o f a sick baby, w ere examples
w here the routine nursing care practices were insufficient an d the participants were called
upon to consider other ways to approach problems.
The paternalistic, hierarchical nature o f the health care system inherently gave
much pow er to the physician. Participants reported having to leam how to negotiate that
power. Even reporting clearly abnormal medical data to th e physician w as considered
problem atic for the relatively new nurse. The participants in this study had to go through
a phase o f initiation whereby their opinions and voices w e re valued. T he participants w ho
recalled facing conflict between the physician’s care and th e w om an’s w ishes, realized
that the decision to advocate or em power a wom an was dependent on th e n u rse’s
know ledge o f the system and how the physician view ed his o r her pow er. The
participants’ abilities to negotiate the distribution o f pow er to obtain perm ission to alter
care routines w ere contingent upon their level o f expertise in nursing p ractice and length
o f tim e w orking in the system. Nurses learned which doctors would share their pow er and
allow the nurse o r the woman to have voice in the decisions, and which ones did not. As
relatively new nurses, this continued to represent an area o f uncertainty for the
participants.
The acts o f advocacy or empowerment represented potentially problem atic issues
for w om an-centered practice. The nursing literature described num erous definitions and
perspectives on nursing advocacy (M illik, 1997; Rafael, 1995). Sim plistic advocacy
defined by Rafael (1995, p. 25) as “ pleading the case for a nother” and paternalistic
advocacy as “ doing something for or to another without th a t person’s consent and on the
prem ise that it serves that person’s own good” are not desirable for w om an-centered care.
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A philosophy o f wom an-centered care underscored the right o f the consum er for
inform ation or sendees necessary for self-determ ination (Shenvin, 1992, 1998). The
participant. Barbara, who described advocating for the w om an to give birth in the LDR
suite, as com pared to the back delivery room did so w ithout this sort o f interaction. She
made w hat she thought w as the best choice for this w om an, believing the w om an
expected to give birth in the LD R setting, that is typical. The context o f the m other being
in active, natural labor influenced B arbara’s ability to explain the situation to the m other.
Barbara w ent on and did w hat she thought w as best in the situation. The participant,
Keith, w ho advocated to keep the Foley from being inserted for a urine test, w as an
example o f consum er-centric advocacy that resem bles em pow erm ent (Rafael, 1995). The
client w as given the inform ation, made a decision, and the nurse supported the clien t’s
decision. This form o f advocacy resem bled the tenets o f em pow erm ent, w here the
consum er is an active and equal participant, who is enabled to gain personal control. The
woman in K eith’s care w as considered a subject, rather than object, who had the ability to
transform her own reality.
T he pattern, Being and Becom ing A W om an-Centered N urse, reflected m y
interpretation o f the stories o f the participants’ experiences developing th eir philosophy
o f w om an-centered care in m atem ity-new bom care settings. The participants learned
w om an-centered care as an ideal for practice in the m aternity nursing course and sought
w ays to practice that philosophy and m ake a difference in w om en’s care. The
participants’ developm ent o f a w om an-centered philosophy o f care w as reflected along a
continuum , together with their practices o f m aternity care routines. The them es,
D eveloping a Philosophy and Putting the W hole Package Together, were the labels I used
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to describe the experiences o f the maternity nurse participants as they recalled the process
o f being and becom ing woman-centered nurses.
C onstitutive Pattern: Tensions in Practicing W om an-Centered Care
The participants faced impediments to practicing w om an-centered m aternity care
as they had envisioned they w ould when they first entered practice. T ensions were
experienced as participants cam e to recognize the barriers to w om an-centered m aternity
practice. As participants established meaningful relationships with w om en during
childbirth and new born care, they realized their abilities to offer choices and alternatives
to routine care w ere often lim ited and controlled by others w ith more pow er. They cam e
to see that som e w om en they cared for did not want care outside the m edical model. The
participants cam e to see how the system o f health care delivery was designed to limit
w om en’s know ledge and access to alternatives o f care. T he barriers to w om an-centered
care limited the participants’ abilities to prom ote w om en’s autonom y and choices in care.
The participants described clinical situations w here the barriers becam e visible to
them and they experienced tensions in their senses o f w hat “ought to b e .” In most cases
the participants sought to resolve the tensions in some w ay, if possible, but this did not
alw ays mean they could intervene to change the situation. Resolution som etim es meant
supporting the w om an through a medically focused event that the participant felt
pow erless to change. Som e tensions were recognized by the participants as being too
pow erful or beyond their control. The participants were required to be w ith the woman
through the experience and often recalled feeling overw helm ed, sad, o r relieved when the
experience w as over. Participants learned to “pick and choose” how they could apply
their w om an-centered philosophy to improve care for w om en. They also learned to
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accept, care for. and educate the women who appeared content with allowing others to
make decisions for them.
The m edical control o f birth often centered around issues o f temporality. T he
participants found them selves as agents to force the birth process to conform to
artificially im posed tim e frames. The participants felt pressured to m ake birth happen
within a tim e frame deem ed acceptable to the physician, w hich is antithetical to a
philosophy o f w om an-centered birth. The participants described clinical situations w here
they believed the m anipulated birth tim e violated w o m en ’s rights and sometimes put
w om en at m ore risk for complications.
The participants worked in a culture o f m edicalized childbirth w here the dom inant
health care delivery system existed to support m edical practices. Participants learned that
alternative options to mainstream medical care in the com m unity were not encouraged or
em braced by the system. Hospital-based prenatal education did not teach alternatives to
medical routines. The participants recognized ways the system was set up to dom inate
women and co-op the natural birth process.
The participants recognized the pow er relationships between the physician, the
w om an-client, and the nurse that played into the tensions. W henever the nurses attem pted
to change situations by advocating or empowering w om en they still encountered
restraints by the system that they felt uncertain in challenging. Participants experienced
tensions in not know ing "the boundaries” - fearing th eir advocacy could go “over the
line.” T he risk o f being reported to their nursing supervisor for insubordination or
unprofessional conduct was ever-present.
Relationships w ith others were viewed as either m aking it easier o r worse to face
tensions in the practice environments. Relationships that had an impact on the tensions o f
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practice included the colleagues they worked with and w om en/clients they cared for.
Participants described relationships wfith colleagues and nursing m anagem ent as key to
their survival in the system . The participants who perceived supportive and caring role
models described professional relationships that strengthened their abilities to deal w ith
tensions o f practice. T hose participants w'ho were not fortunate to have peer o r
management support described m ore difficulty living through the tensions alone.
The participants’ relationships w ith w om en/clients represented a potential tension
to practicing w om an-centered care. M others o f sick infants who seem ed passive and not
interested in m othering the infant w ere problematic for N IC U nurses. W om en w ho
entered the system uninform ed about the medical regim es they w ere about to undergo,
such as induction o f labor, were problem atic for the participants. The participants
described feeling anger and frustration with women w ho w ere passive and uninform ed
about their experiences. The w om en’s attitudes and lack o f childbirth education and
preparation were view ed by the participants as barriers that limited th eir abilities to be
woman-centered. The participants accepted the w om en’s choices for m edical care and
attempted to provide sensitive care, yet they expressed frustration in carin g for w om en
who seemed so uninform ed o f the risks and actually pleased to be in the hands o f the
medical m odel o f childbirth.
The themes for this pattern are: Temporality: A Tim e to be B om , W om an-
Centered Care in a M edically Focused Environment, and Relationships. T hese them es
represent m y interpretation o f the participants’ experiences in facing the tensions o f being
woman-centered in practice.
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Theme: Tem porality: A Tim e to be B om
T he participants described tensions associated w ith obstetrical tim e m anagem ent
that put them in precarious positions. Participants w ho w orked in birth settings
experienced a constant pull between the natural process o f birth for a w om an and the
m edical m odel o f birth. T he medical m odel usually sought to speed along the natural
process o f birth to have w om en give birth w ithin a specified tim e frame. The participants
told stories o f being caught in the m iddle o f a struggle to protect the w o m an ’s dignity and
her right to give birth at her ow n speed o r at a speed the nurse felt was adequate, rath er
than forcing the speed o f labor and birth to conform to the convenience o f the birth
attendant. A m y, Nicole, and Steve who each w orked in labor settings described instances
w here they lived through the tension o f tim e as they attem pted to provide woman-
centered care. T heir ability to negotiate the tension w as dependent on the context o f the
situation.
Am y described the labor and birth setting that she w orked in as one where use o f
pitocin to induce or augm ent labor was a standard practice applied to alm ost every
wom an. At any tim e the w om an failed to m ake a steady dilatation o f 2 centim eters p er
hour the physicians believed pitocin should be adm inistered. Amy described how this
usually happened,
Pretty much the docto r goes in and says w e’re starting you on pitocin
cause y o u ’re not m aking any change and you need to m ake change or
w e’re going to have to do a C -section. I mean y o u ’re not progressing and
the ladies all say okay.
The decision to induce o r augm ent was usually made betw een the physician and the
w om an. A m y felt she had no other choice than to im plem ent the physician’s orders. M ore
problem atic for Amy w ere instances she recalled w hen the physician ordered pitocin
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despite the fact the wom an was progressing adequately in labor on her own. She believed
the physician ordered pitocin so he could deliver the woman before 5 p.m,
I had a patient progressing in labor on her ow n at the correct 2cm/hr. The

M .D. w anted to start pitocin anyway. I’m sure so he could deliver her
before 5 p.m ., for his convenience. This happens often.
As Amy m anaged the rate o f pitocin throughout the labor she believed the goal for
adequate contractions and cervical dilatation should be the param eter for deciding the
rate. Amy recalled a situation where the woman was dilating at the “norm al” 2
centimeters per hour so she did not increase the rate o f pitocin as th e physician desired.
This resulted in the physician complaining to A m y’s nursing supervisor and asking the
supervisor to “talk to her about that.” Am y stood up to the nursing supervisor by telling
her supervisor she was not increasing pitocin when the patient w as progressing normally.
A m y was a labor nurse w ho resisted the tension to conform to external pressure to “get
her delivered,” according to someone else’s schedule, but this resulted in a com plaint to
her nursing supervisor.
N icole described a “pow er situation” she was involved in w here the tension o f
tim e was a strain that put the wom an at risk for an unnecessary cesarean birth. N icole
lived through the conflict o f tw o different physician’s opinions o f labor management.
Nicole used the tools o f technocratic birth (her ability to increase the rate o f pitocin) as
her only w ay to prevent w hat she considered the w orst option, a possible cesarean birth.
Nicole knew she had until 6:00 p.m. to facilitate com plete dilatation o r the doctor on call
(Dr. Y) was going to perform a cesarean,
There was a largely obese patient, largely obese, she was about 5 ’4” and
over 300 pounds. Dr. X was taking care o f her and she was being induced
and she was going very, very, very slowly, very slo w ly ...It w as Dr. X ’s
patient and he was taking care o f this lady. Dr. Y., who is going to be the
6:00 p.m . cover, decided that this patient needs to be a C -section. She
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needs to be cut. She’s not going to deliver from below. Well Dr. X said,
well no. I think she’ll deliver from below, I think we ju st need to g iv e [the
woman] some time. I think she’s going to deliver. The two o f th e m go
back and forth. He’s (D r. Y) is so well spoken that he can talk a n y b o d y
into anything. But Dr. X said no. I think she can deliver from b elo w .
Nicole feared that Dr. Y, a “pretty powerful man” w ould autom atically perform
the cesarean birth when he took over the case at 6:00 p.m.
Dr. X com es in, then he leaves and Dr. Y. comes in, comes and ch eck s
her, I m ean even before 6:00 p.m. because he wants a c-section set u p for
6:00 p.m. So he (Dr. Y .) wants to be done at 6:00 p .m .. ..I m ean th is is the
same doctor who does all the forceps and attacks the patients w ith o u t
letting everything progress and its ju s t.. .you know as a woman, th a t’s the
frustrating part because for one thing, she (patient) is very, very larg e, so
you want to try and avoid a c-section or surgery if possible. So w h y w ould -
you electively do som ething that could be done w ithout su rg ery .. .1 d o n ’t
think she had the chance, she w asn’t given the full chance if h e ’s (D r. Y)
ju st going to decide to do a C-section on her. You know', taking all th e
power aw ay from her and the w ay he (Dr. Y.) speaks, h e ’s so w ell
spoken...
N icole felt it was only through her efforts w ith progressive pitocin in d u ctio n and the
w om an’s attending physican, Dr. X standing up saying, “no, no, no, ju st le av e her alone
and she can do it,” that the w om an did dilate and avoided a cesarean. N ic o le resolved the
tension o f time and the threat o f a cesarean birth by focusing on medical interventions to
support the w om an’s cervical dilatation,
Well I sat her up and I upped the pit some more. I did all that stu ff th a t I
could do to try and get h e r to complete. She had a right to a deliv ery , to be
given that shot, to have that chance.. .just because he (Dr. Y.) w a n ted to
get home, because he w as on the phone at the nurse’s station calling his
wife saying, look I have got to stay..I have to stay until after (6 p .m .)....
Then 6:00 comes, all o f a sudden she’s complete. 6:30 she had a v a g
delivery. So it worked out, it took Dr. X. standing up saying, no, no, ju s t
leave her alone and she can do it. And she ended up doing it. It w as lik e a
triump [laugh] and the baby was a m ere 5.3 pounds o r something. I ju s t
felt good for her, that she acutally did all this. Although he (Dr. Y .) s a id , I
d o n 't know how w e’re going to get these big legs up on the stirrups
anyway..all that kind o f stuff.
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N icole “ upped the pit" as a medical intervention to facilitate the w om an’s dilatation and
gave her a chance to deliver vaginally. N icole felt this “power situation" forced the birth
o f the baby to occur by 6:00 p.m., one w ay or the other. For N icole the resolution o f this
tension centered on prom oting cervical dilatation w ith pitocin to w ard o ff the inevitable
possibility o f a 6:00 p.m . cesarean birth dictated by a physician w ho had m ade it clear he
wanted this delivery done by then. N icole shared her feelings o f discom fort being the
nurse in this situation, and her feelings o f trium ph for the w om an w ho gave birth to her
baby.
Steve, a labor and delivery n u rse in a busy teaching hospital, described how the
tension o f tim e impacted a young m o th er’s birth experience. Steve believed tension o f
tim e led to the wom an having an unnecessary forceps delivery and there was nothing he
could do to change the series o f events. In this situation time was a factor at several
different levels. The w o m an ’s progressive pushing efforts during second stage labor were
occurring too slowly for the birth attendants. W hen the decision to use forceps w as made,
Steve felt he had inadequate time to plead a case against the use o f forceps and advocate
for the w om an. Steve believed the delivery room setting was the w rong time to confront
doctors’ authority to m ake this decision. He also questioned his authority as a nurse to
challenge the physician on the birth techniques,
I had a patient, she was a [15 year old] prim igravida and she was pushing
for quite some tim e, and she w as getting there but it was slow , slow,
s lo w .. .So everything was going to m e from w hat I was able to see, was
going to where this person could have, with a little patience o r coaching
and som e w ork, have a vaginal delivery without forceps assistan ce...A n d I
personally felt in m y heart - and the doctor who made the call I think is a
good doctor and I worked w ith him in cases before and I felt com fortable
and confident w ith him - but he w anted to teach som eone under him how
to use forceps...because the opportunity was there and this person was
like m aybe a third year [resident], the other doctor was like a first year
[resident], and he wanted to give this [first year resident] person some
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experience on using forceps. I was really kind o f like throw n back when
the request was made for forceps. I w as like forceps? A gain I was
conscious not to make it a conversation piece in the room . ..the doctor
requested forceps so I got the forceps and put them on the sterile fie ld ...
Steve was w illing to continue to w ork w ith th e young m other to facilitate pushing efforts,
but the residents w ere not willing to wait and actually saw her slow progression as an
opportunity to practice forceps application. A s a nurse for two years, Steve felt pow erless
to prevent the use o f forceps and experienced the tension o f seeing an unnecessary
procedure being planned. Steve felt he was in an awkward position but in his ow n way,
let them know he questioned their decision,
And so I’m sitting here basically saying to myself, well there was nothing
to m e that really, really was indicating forceps. So I kind o f like stood by
him. he was at the perineum and I said forceps? And he gave me that look
of, you know, well you k n o w ...th is is allow ing the other person to get
forceps experience...I felt that particular patient was being used almost
like a guinea pig because she was in a teaching hospital and you know she
was there, she had no voice, she had no say and I was saying, being that
she didn’t know what was going on an y way, I felt kind o f funny that I
couldn’t really say anything to stop it w hile it was happening because
w hat I ’m going to say, okay, I’m not going to give you the forceps? H e’ll
get them anyway. 1 mean I felt pow erless to challenge w hat was
happening and I didn’t think it w as right. A nd I couldn’t advocate for the
patient in that aspect. I m ean everything w ent well. There was no traum a
but still, it w as an unnecessary procedure that usually results in some type
o f tear or laceration.
Steve was faced with assisting the resident doctors to apply forceps and facilitate
a vaginal birth for a fifteen year old prim agravida. Steve’s clinical perception, based on
his two and a half years o f labor and delivery experience, was that with more tim e and
coaching, forceps w ould not be necessary. H e feared the perineal trauma that he had
observ ed in other cases when forceps were used by novice doctors. Steve questioned the
resident's decisions but could not stop him because it was a m edical “call.” Steve was
relieved the procedure went well and talked about how he felt being in the situation,
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The barrier [to advocating] was time. It w as all happening right then and
th ere.. .And I d id n 't have an opportunity to sit back and get it all
together...you’re doing a lot o f other th in g s...y o u ’re doing everything by
yourself, and this person asked for forceps. I do believe in the hierarchy
system, the doctor w rites the orders, for appropriate orders, the nurse
executes them. It ju st w asn ’t the time to ...I didn’t feel like I was in a
position to really challenge either, based on what? I couldn’t justify that
any way other than m y gut feeling. B ut I knew and he knew there was no
need for forceps except to give that first year experience.
Afterwards, Steve sought further resolution o f this situation, although he could
not change what had happened. H e recalled again confronting the third year resident after
the delivery was over and m ade the resident agree that “yeh, forceps w eren’t needed but
the first year needed some experience.” Steve recalled he felt some satisfaction w ith this,
because it validated his clinical perception o f the situation and as the w om an’s nurse he
w anted the doctors to know he did not agree w ith the decision.
In these situations A m y, Nicole, and Steve each lived through the tensions in
providing woman-centered care to women in labor and birth w here conflicts existed
betw een natural birth and the m edical time clock. T heir experiences were exam ples o f
how the medical model o f care, w hich permeates clinical settings, determines tim e for
birth rather than the w om an’s body. This b elief is contrary to a philosophy o f w om an-
centered birth. The participants felt discomfort in these situations, but as agents o f the
hospitals, they had a role in carrying out the m edical decisions. Each participant sought
resolution to the tensions caused by time, although their ability to alter the situations
varied.
Theme: W oman-Centered Care in a M edically Focused Environment
The participants practiced in health care system s that for the most part w ere not
designed for woman-centered birth and newborn care. They described barriers em bedded
in the system that co-opted woman-centered m aternity care and prevented them from
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practicing w om an-centered care as they w ould like to do. The barriers lim ited the
participants’ abilities to prom ote the w om an’s autonom y and choices, especially during
labor and birth. As the participants found ways to “pick and choose,” w hat aspects o f
w om an-centered care they could implement they w ere acutely aw are o f the lim itations to
their practices and options o f care for women.
The participants coped with the barriers in various ways depending on the
context. Som etim es the barrier, such as the high labor induction rates, could not be
changed and they lived through the frustrations o f know ing how this lim ited labor options
and w om en’s experiences. O ther times the barriers w ere challenged, su ch as in instances
w hen care rituals prevented a mother from holding and breastfeeding h e r baby at
delivery.
The participants described the atmosphere o f the m aternity u n its as being “very
m edically focused,” busy, and potentially impersonal. The participants recognized th e
pitfalls to the w ork environm ents and the need to rem ain mindful o f th at as they looked
for openings to practice woman-centered care. The participants’ aw arenesses o f th eir
environm ents dem onstrated how they lived in a world o f m edically-focused m aternity
care, w hile being mindful that they could use their philosophy o f w om an-centered care to
make a difference.
Barbara, a labor and delivery nurse for a year and a half, spoke about her
awareness o f the barriers embedded in the system in w hich she w orked. Barbara
recognized the tensions o f working in a busy unit w ith m ostly medical routines, but she
was optim istic that her woman-centered values helped her think differently and opened
her to look beyond the medical aspects,
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The piace I w ork now is so busy, and fast p a ce d .. .it's very easy to be
im personal and ju st very m edically oriented. V ery much do w hat you’ve
got to do, get som ebody delivered because y o u 're thinking w e still have an
induction w aiting to be adm itted who has been there three hours. I think
having that background [wom an-centered] at least to the best w e can, as
far as tim e constraints, it gives you another outlook on how you can
approach them and their labor. I think it’s to me. It’s more o f a frame o f
mind o f how you picture w hat’s going on w ith them than it is like any one
particular th in g .. .1 think it gives you a different view [o f w om en’s care]
instead o f ju st looking at it medically.
M edically-focused birth w as described by the participants as the norm, w hile
wom an-controlled, natural births, o r birth plans that provided some degree o f autonom y
for women, were the anomalies. M edical birth w as described by participants as being the
usual type o f patient situation that the health care delivery system prepared them to
anticipate. Hannah, a labor and delivery nurse for a year, described how the orientation
process was designed to teach traditional care. The orientation period only prepared
nurses to deliver m edically-focused routines,
I think that som ebody com ing in following the traditional labor plan is
more so easy to som eone like us - that’s w hat w e were trained to know
when we got out o f orientation. You know that was the norm. The not
norm was the Lamaze p a tie n t.. .scream ing at 9cm and uncontrollable.
The participants realized the medical m odel o f care was designed to control
w om en and limit care options. T he participants w ere aware o f their com plicity in this
model, as em ployees o f the system. Connie, a labor and delivery nurse, described h o w the
medical environm ents w ere designed to give the control to the caregivers,
A lot o f tim es you know w hen we have epidural deliveries if the doctor’s
not there, w e ’ll ju st tell them , w e’ll turn the Pit o ff,...p u t their legs down
and tell them not to push any more i f th ey ’re fixing to crown. B ut these,
[natural births] there’s no, no control by the nurses whatsoever. It’s totally
w om an-centered.. .A lot o f com m ents are m ade [by staff], oh G od, they’re
going natural, w ell w e’re going to be hearing screaming. You know , that
kind o f thing. I think the m ajority o f the staff w ould prefer to have our
normal epidural patients that w e can control.
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T he participants w ho worked in m aternity areas identified the routine medical
orders as the m ajor lim itation to providing woman-centered care. Participants described
physician’s adm ission orders that were designed for a m edically controlled birth. These
orders usually included bedrest, continuous electronic fetal m onitoring, and induction o r
augm entation w ith pitocin. Epidural anesthesia w as ordered during early labor. The
participants w ho cared for w om en in labor felt they were expected to im plem ent these
orders w ithout question. A ny deviation from these orders required physician approval.
The participants who w orked in labor and delivery described the tension o f negotiating
the rituals o f m edical care know ing the rituals limited w om en’s choices.
M eg and C laire’s experiences in labor and delivery o v er the past year and a h a lf
dem onstrated how the participants viewed their w orld o f practice, full o f barriers to
w om an-centered care. M eg ’s description o f the m aternity unit illuminated the lim itations
o f care caused by the d o cto r’s regim es o f care, w hich women and their nurses accepted as
the norm,
The doctors have their w ay that they want to do things. They don’t believe
in letting m om g et further in her progress o f labor and then breaking the
w ater and those kinds o f things. They have a routine. T hey get to the
hospital, you start the IV, you start them on Pitocin. T hey come in, they
break their water. D o esn ’t m atter i f they’re one finger tip, i f they’re a
fingertip then they can break their water. They break th e ir water, they
w ant them to get the epidural and its ju st pretty much straight forward.
W hen you com e in to the hospital, you are pretty m uch stuck in the bed
w ith the m onitors on you, blood pressure c u ff monitors. Y ou’re pretty
m uch in bed the entire tim e .. .occasionally they’ll let you get up and w alk
around. I f they’re on pitocin then they can get around and walk along the
side o f the b e d .. .A nd w e try to accom m odate as far as w e ’ll put a chair
next to the m onitor and let them sit in the chair, it’s 2 to 1 ratio, patient,
nurse and so it’s really hard to give that care that m om needs, to give her
all that attention, to be there as her caregiver, it’s really hard.
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Likewise, Claire described the medical environm ent that dictated routine care and
impacted her relationships w ith women, that are so im portant to providing woman-
centered care,
Well it’s very difficult to practice w om an-centered care in the

environm ent that I’m in because I ’m in a very, very, very fast paced
environm ent...so m ost o f the time I ’m going to have two patients and
they’re usually on pitocin, which m eans I have 15 m inute checks on both
patients. So every 15 m inutes I have checks on both patients. So that
doesn’t leave me any really room to com m unicate and talk and try to get
the com fort m easures in and get a relationship going to w here I could use
any o f that w om an-centered things that we talked about and at first when I
was practicing it kind of, I was very d iscouraged... shoot, I d o n ’t even get
a chance to influence these women because I’m so busy. I m ean I have no
ability. The only tim e w e’re one on one is when they get to the pushing
phase, you know, com pletely dilated, second stage o f birth. So at that
point, it’s already been decided, pretty much.
Claire coped w ith this environm ent by eventually requesting to w ork the night shift
where she w as less busy and had more time to establish relationships w ith women so she
could make a difference in their care. The environm ent o f m edically-focused birth,
however, rem ained som ething Claire, like the other participants, had to adjust to as she
looked for opportunities to challenge the barriers to w om an-centered care. Claire
established relationships w ith women and sought opportunities to influence care. The one
aspect o f care that Claire challenged was the rituals o f nursing practice during the birth.
Claire based her actions on h er belief that every m other deserved to hold her baby as soon
as possible. M ost doctors do not place the baby directly on the m other, but give the baby
to a nurse who provides im m ediate care on the baby. This is w here C laire drew the line.
Claire described herself as the nurse who “takes charge” and gets the baby to the mother,
So as soon as the baby is out, they bring the baby over, you know, dry him
or her off, make sure they ’re breathing okay and then the bab y ’s nurse has
a list o f things that she needs to do — But what the nursery nurses does
now, I m ean m easuring the head circumference, the length, all this stuff.
The w hole entire physical assessment. T hey’re trying to get done before
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the mom even as much as holds their baby, much less b re a stfee d s...sh e ’s
sitting up looking at her baby over there being assessed. The baby is fine,
it’s time for his mom and dad to see him. A nd I take charge o f that. I ’m
like, I’m taking this baby, [laugh] You can finish this la te r...S o w rap the
baby up, bring the baby over, give them th eir 10 m inutes o f bonding,
personal tim e, you know, m aybe just stand in the com er and let them have
their time together and then i f she wants to breastfeed I tell her, look now
is a good tim e to breastfeed if you want to do that.
Participants described h o w they negotiated barriers w hen w om en desired
more control and options outside the routine m edical orders. Participants to ld o f
having to negotiate their care w ith the physician and other nurse colleagues to
protect the w om an’s choices and h er sense o f autonom y. Claire described h o w she
did that in her practice,
It’s sad b u t.. .1 really don’t get to practice the w om an-center care in m y
clinicals at all basically because it seems like everybody is opposed to it.
Opposed to people com ing in with a birth plan. Opposed t o .. .and th en if
they don’t talk to their doctors about it before hand, they ju s t hand m e the
birth plan. I c a n ’t do anything. They have standing orders. Everybody gets
an IV, everybody gets continuous m onitoring. And they give m e th eir
birth plan saying I want to get up and w alk around and I’m like, I c a n ’t do
anything for you. I have to call the doctor then at 2:00 a.m. in the m orning
because rem em ber I w ork at night. Your patient brought in a birth p lan
and they w a n t.. .the doctors are not happy. W ell I didn’t know anything
about this and so then w hat do I do. I’m in a position I cannot go and
detach them from the m onitor unless I have a doctor’s order. So then they
can’t walk around. I can g et them up and they can pace right back and
forth as long as the cord w ill allow them to. I get them up in the little
rocking chair hooked to the monitor, I can do all that, but to get them [up].
I can’t do that o n m y own. T here’s nothing I can do on m y ow n for th at
point.
The participants in this study viewed the w om en who planned natural birth o r
cam e w ith a birth plan as special and a welcomed diversion from the m edically controlled
births. The participants looked forward to working w ith the w om en and using all th eir
com fort skills related to w om an-centered care. Yet the participants w ere aw are o f the
conflict in goals betw een the w om an and the system o f care designed to control w om en.
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The participants recalled their awareness that not all nurses o r physicians valued this
perspective o f birth. The participants realized the system could still co -o p t the w om an’s
goals. Claire believed for these women to be successful they needed a “ m ediator” and she
described how she acted as a m ediator to protect the fam ily’s birth environm ent from
other staff w ho m ay not value w om an-centered care,
Just trying to be a m ediator between the patient and other nurses and the
doctor, trying to ... i f I go out and say, oh my patient is doing so good.
They’re six centim eters. They haven’t gotten their epidural. T h e y ’re doing
great. A nd som ebody [staff] says, oh give it 30 m inutes. I tell th em no.
She’s doing w onderful. O r say, I’m going on a lunch break. I ’ll tell the
nurse, look she really likes to have pressure on h er back. Do n o t offer the
epidural. She does no t w ant to be offered the epidural. She does not w ant
to be offered D em erol. D o n ’t offer her that. T hey’re doing w onderful
together. I also encourage the dad, the support person, the husband to take
an active role and m ost o f the time, the ones that com e in natural and it’s
very rare, I mean these few that I have done, m aybe a handful, five o r six
natural deliveries that I ’ve been in, in almost two years, the dads are
prepared and they take their role and the doula, if they have a doula, they
kind o f have their thing going on. So I ju st act as a m ediator at that point
between the couple and their doctor or the other nurses that th ey m ight
come in contact with.
Helen described tensions caring for w om en after birth in which the environm ent
o f the unit was not conducive to the mother w ho wanted special things. She identified the
physical set-up and rituals o f care that the unit was not w illing to change. H elen realized
staffing and the philosophy o f the unit precluded individualized care. S he cared for a
patient that was labeled as “difficult,” because the system could not accom m odate her
requests,
I think really the m ost difficult type o f patient is the patient w ho they
typically send a letter to the hospital first saying, I never want th e baby to
leave m y side. I w ant the baby bathed w ith me in the room ,— all the shots,
everything [to] be given in the room. T h at’s a little m ore difficult because
our room s aren’t set up. W e don’t have warmers in there. We d o n ’t have a
lot o f the ability, the space, the products that we need. G lucom eters, the
baby’s cold and the blood sugar d ro p s,... it ends up as more o f a one to
one [staffing]. W e have a very high ratio o f patients. O u r agency like has
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6.400 babies a year. It takes a little bit more o f our time, but really it's
more the initial couple o f hours that kind of, w e need a little bit more
staffing to do that type o f nursing, and w e don’t have that - and I would
say that w ould probably be the m ost difficult thing that w e have to deal
with. W ho’s going to end up w ith her? A nd th at’s horrible b u t...o k ay , this
is the kind o f hospital w e are and then to adapt that to w hat som eone else
wants [individualized care]. A nd we kind o f go, oh there’s a birthing
center 30 m inutes away, please go there, [laugh] That’s w hat you w ant and
that’s not the kind o f hospital w e are. We ju st don’t, we d o n ’t have the
staff. W e d o n ’t have the setups for th a t...
Helen’s unit refused to take on the image o f a m other/baby unit that could
accommodate that individualized requests. The patient census, staffing ratios, and
physical set-up w ere not conductive to these requests. Realizing this, Helen believed the
best option for this m other was to recom m end the birthing center thirty miles away.
As em ployees o f the hospitals and health care systems the participants faced
opportunities w here they w anted to share information with w om en that would help them
make better decisions about their care. This was problematic for the participants who
desired to advocate for women, but felt a professional obligation to support the
physicians’ practices or the institutional protocols. Renee and M ary described instances
w here this was problem atic. T hey both found ways to maintain th eir professional
obligations to the institution and to the women they care for.
Caring for wom en everyday who are victim s o f the rituals o f practice represented
a tension for the participants. Renee, a nurse on a postpartal unit for two and a h a lf years,
talked about the frustration o f know ing certain women she cared for got episiotom ies on a
routine basis because o f the physician they chose. Renee illum inated the participants'
frustration in being uncertain about how to provide information that m others needed to
make choices w hen it concerned their medical care provider,
.. .because you know this doctor’s philosophy about a first tim e mom, h e ’s
not going to let them do the w ork they need to do to push the baby out.
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H e’s going to go up and pull the baby out. And as a nurse, I ju st find that
frustrating and upsetting... You ju s t want to say, God, I wish you hadn’t
gone to this doctor. I wish som ebody could have told you what his
philosophy is and how do you do that? You know, and there’s one doctor,
I’ve been on this unit as a nurse for a little over 2 years and in 2 years time
I have seen her cut the heads o f tw o babies that required stitches. A nd I
called 1-800-CONCERN [anonym ous hospital hotline] and gave the
patient’s name and the doctor’s nam e and said, you need to start a track
record because this is a dangerous d o c to r.. .and the last one that happened,
she [doctor] had the nerve to tell th e patient that her bones didn’t open
enough to allow the baby to com e through and the m other’s bones cut the
baby’s head. And I ’m like, this is a first baby for this m other.. ..So I
suggested that she check that ou t w ith another doctor and see i f they had
ever experienced that with any o f th eir patients. I can ’t say you shouldn’t
be going to this doctor, but as a nurse I have to be an advocate o f the
patient and let them know there’s other knowledge out there that they
should [know], but that part I find upsetting when I know som ething’s
really wrong and as a nurse’s role, how m uch inform ation do you give the
patient without going over the boundary? I don’t think it’s my right to
say. Oh, my God. T hat’s an aw ful doctor cause that’s very subjective and
with confidentiality you can’t say, you know she sliced open another
baby’s head ju st six months ago. I really d o n ’t know, except for 1-800-
CONCERN, I really don’t know w hat you do with that.
Renee kept silent about the doctor who autom atically does an episiotom y on every
prim agravida. She felt powerless to change this. As a postpartal nurse this had been her
observation o f this physician’s practice, but she could not validate her suspicions. Renee
lived through the tensions o f caring for w om en postpartally, knowing how the episiotom y
affects women. However, she decided on a safe boundary in w hich to take action
regarding the doctor who cut a baby’s head during the episiotom y and gave the m other
false information. Renee advised the m o th er to seek a second opinion and reported the
incident in a w ay that kept her anonymous.
M ary was faced with similar concerns as she learned how to go about being a
w om an-centered childbirth educator for a hospital-based prenatal class that was intended
to prepare w om en and partners for the m edical routines. M ary described how the prenatal
classes limited her ability to teach wom en about alternative options and birth planning.
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She told o f having to follow a curriculum o r script approved by the education com m ittee
m ade up predom inately o f obstetricians w ho practice at the hospital,
.. .the first thing I w as supposed to talk about was a birth plan and how
everyone should develop a philosophy o f birth, and I’m supposed to be
teaching from this curriculum . So the first tim e I get up there to teach I
started talking about all that and at the break m y p receptor...cam e up to
m e and said w e’re not supposed to be teaching about the philosophy o f
birth and birth plans any more. I’m like, w hat are you talking about? It’s
on the script. It’s right h e re ...S h e said it d id n 't get approved [by the
com m ittee]...I had a long sp iel...ab o u t birth plans and developing your
ow n philosophy, personal philosophy for each o f w o m en ... Well I d o n ’t, I
d o n ’t say that any more, whien I get to the episiotom y o r to the forceps, I
kind o f weave it in - in m y ow n w a y ...
M ary found herself facing an ethical d ilem m a o f following a script that dictated only
w hat a m edical hospital com m ittee said she could teach, as opposed to teaching w hat she
thought the women and their partners needed to m ake inform ed choices. M ary described
how she faced this barrier by using the clien ts’ questions to lead into discussions w here
she encouraged them to explore alternatives through self-education and consultation w ith
their physicians,
W hen I get to the episiotom y I tell them , look if this is som ething that
y o u ’re opposed to, i f this is som ething that y o u ’re not sure about, you
need to research it. Talk to you doctors about it.. .1 definitely tell m y class
in each o f these situations, you need to m ake these decisions on y o u r own
and discuss it w ith your physician. D o n ’t ju st lay there passively and let it
happen to yo u .. .In m y classes I com e in contact w ith couples who are
m arried couples, their first baby. T hey’ve done a lot o f reading and
research and they’re com ing to the class and they’re well prepared and
they know their stu ff and so w hen they start raising their hand and saying,
w ait a minute I d o n ’t w ant vacuum extraction used on m y baby. I can
address that and say, you know, a lot o f people have that concern and I ’m
glad y ou’ve done research and you d o n ’t w ant that used. You need to talk
to your physician. A nd I’m also able to tell them w hat role the epidural
plays on having all o f these different things occur, the episiotom y, the
vaccum extraction, forceps, all that stu ff so that they can try to m ake a
better decision. In the classes I ’m able to better express that to them , help
them to know that they do need to figure out w hat they want in th eir birth,
m ake a plan, make a list, bring it to their doctor, get it approved and talk
about it before hand and not at the hospital, because it doesn’t w ork that
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w a y .. ..I'm able to kind o f feel it out at the beginning and decide w hat I ’m
going to talk about as far as wom an-centered.
M ary was a relatively new childbirth educator who was not ready to take on the
com m ittee to change the focus or philosophy o f the classes, yet she found a w ay to
negotiate this tension in her practice and applied a w om an-centered philosophy that
opened the door for w om en to m ade more autonom ous decisions in their care.
The participants who worked in N IC U areas also articulated experiences that
revealed tension in practicing w om an-centered care in a m edically focused environm ent.
The nurse participants in NICU described barriers and challenges that centered around
keeping a hum anistic perspective for the babies and families w ithin the inherently high
technological environm ent that existed for the w ell-being o f the baby.
N IC U nurses described how the high technology settings, necessary for the
survival o f the baby, can also be a deterrent that keeps them from focusing on the human
experience o f caring for a baby and establishing parent-infant relationships. T he
participants described that it was the focus on the baby as a m em ber o f som eone’s fam ily
and prom otion o f the parent-baby relationship th at helped them look beyond the
technologic focus. V icky described this,
W hat helps out like when things are really high stress, you ju st stop, step
back, look at the picture, this is a little baby, you’re doing all you can for
them and you know like when the m om and dad come in, that will give
you a little break...because you have to stop all the high tech thinking and
calculating and you come back down to earth and you can talk with the
parents and explain things to them and it ju s t kind o f gives you a break
from the constant rigamaroo o f [high tech] caring...S o that gives you the
break, you know away from [technologic care]. It’s alm ost like you c a n ’t
w ait till the parents get in there som etim es ju st so you can talk with them ,
tell them w hat’s going on and how the b a b y ’s doing and all the different
instrum ents that you use and stuff. N ot that you want to overload them
im m ediately. Just basic stu ff like a cardio/respiratory m onitor and pulse
ox and stu ff like that.
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The tensions o f working in stressful, high technology, m edical-focused settings
ham pered the participants from practicing w om an-centered care as they w ould like to in
m any situations. The participants recognized the medical model inhibited w om en’s
autonom y and informed choices for alternatives o f care. The nurse participants in this
study faced the tensions and worked to overcom e barriers when w om en requested their
help or when they felt it was in the best interest o f the w om an/fam ily to be informed o f o r
be offered alternatives. W hen women chose to follow o r found them selves in the medical
m odel o f care, participants supported the w om en and provided nursing care to safely
m onitor the m edical procedures and care regim es and sought opportunities to provide
hum anistic care.
Them e: Relationships
The participants identified relationships with others as integral to their world o f
practice. The tw o relationships described b y participants that greatly influenced their
abilities to cope w ith the tensions in the w ork environm ent were their relationships with
the women they cared for, and their nurse colleagues and m anagers. Caring for women
w ith health care values different from than their own represented a tension in the wom an-
nurse relationship and was considered a challenge to being w om an-centered and affecting
w om en’s situations. Yet the tensions associated with w om en-centered practice were
considered m uch more manageable when the participants perceived supportive
colleagues or managers. The participants perceived their relationships w ith colleagues o r
m anagers m ade it either easier or harder to deal with the tensions o f practice.
Participants who worked in supportive environm ents described the m eaning o f
that experience. M eg believed fellow nurses who “lend a supporting hand” helped her
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adjust to the stressful atmosphere o f a busy, high volum e labor and delivery unit. She
described the supportive environment,
Like a bond, w e all, like a sisterhood. I m ean everybody there w orks to

help everybody. You know, everybody there is there for everybody.
Everyone know s what everyone is going through. So it’s really nice.
W e're very supportive o f each o th e r which I have had friends w ho are
nurses who tell m e that it’s not like that in a lot o f other fields. T hey’re not
as supportive. But you will n e v e r be left stranded in a situation, you will
never, everyone will do everything they can to the limit they can w hich is
really nice. I think that w orking at a high risk hospital w here w e have such
the load that w e have if you d o n ’t stick together it could b e very disastrous
and I think everybody knows th a t and everybody is aw are o f that. W e all
have very sim ilar personalities w orking together. So it’s, you know , I
think that w e know if it w o u ld n ’t, as much tim e as w e spend there, if w e
did n ’t lend a hand to each o th er, it would be extrem ely m iserable. To
w here as everybody lending a h an d makes things, makes it a better job,
m akes it m ore enjoyable.
The participants spoke o f p o sitiv e role m odels, preceptors, and m anagers that
supported them in getting through th e initial orientation period. Participants
acknowledged specific peers who “ta u g h t them a lot” or charge nurses w ho reassured
them after an em ergency situation o r a “ great OB nurse” who “took m e under h er w ing.”
As a new graduate learning to negotiate w om an-centered values in the realities o f
practice, Peggy articulated her gratitude for working w ith a nurse m anager she considered
her m entor and role m odel for w om an-centered care m aternity care,
S h e ’s been a nurse for twenty som ething years, very know ledgeable. She
does both labor and delivery a n d postpartum. So she’s the one w e go to
and she’s also a lactation consultant who has taught me a lot and she
encom passes the M idwifery ty p e model and everything...B ecause she
alw ays listens to what the p atien t wants. She doesn’t ju st go from the
m edical model like during h er labor and delivery. I’ve observed her.
S h e ’ll hold o f f if she knows the m om doesn’t w ant that epidural. She will
do back m assaging. She will do perineal m assage if that’s right before
they're about to birth, if they d o n ’t want an episiotom y. She does the
counter pressure and she u ses aroma therapy. She w ill bring in and do
that. She’ll ju s t use, she’ll try to get in tune w ith that person and ju st
totally be centered on h e r.. .She ju s t works w ith the m other and tries to do
w hat she w ants to do, not necessarily what the doctor w ants her to do.
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She’ll go out there and tell the doctor, no the mom d o e sn ’t want to do it
that w ay. L et’s try it this way. Give m e a chance to do it this w ay. Let me
do the k in d .. .let m e do the back massage, let me do w hatever it takes to
get the m om through this point because she doesn’t w ant the e p id u ra l....It
means a lot that she respects the individual. I look up to her. She has given
me, I look at her as like an instructor. S h e’s just taught m e so m uch. I
respect h er for who she is and also for her nursing ability and for not
giving into all the physicians all the tim e even though she may g et ream ed
out. [laugh]
Helen told o f the im portance o f having peer support during tough situations. Her
first encounter w ith perinatal death went sm oother for her because o f the support she
received from her peers,
I never had to hold the baby and it was, the baby died at 10:00 a.m . and I
was taking care o f this baby like 8:00 p.m . So, you know , discoloration
and the rigor mortis and ju st really cold and I didn’t like that m u c h ...T h e
nurses that I work w ith are very supportive and they helped me and
som eone had done it the past and it did n ’t seem to bo th er them qu ite so
much, but they also w eren ’t taking care o f the family. So you can kind o f
be a little bit more detached.
Participants who described w orking in settings w here there w as very little support
from staff usually verbalized m ore stressful feelings. They voiced more difficulty
adjusting to the dem ands o f nursing. Often these participants changed units o r agencies
w ithin their first year o f em ploym ent. Claire described being all alone in a difficult fetal
dem ise situation w'here the w om an’s baby had been dead ov er four days and she w orked
w ith the m other to push for forty-five minutes before the baby w as bom . F or C laire,
being all alone w as what m ade the delivery m uch more traum atic. It was so busy that
night the charge nurse was unavailable to help her o r offer support,
It was one o f those nights where it was w ild and I felt so em otionally
drained. I w as just so upset and I just really, I felt like I was a w alking
zombie, im m ediately after. I mean all the nurses w ere...laughing, jo k in g ,
eating popcorn, it was busy, but if you have two patients on pitocin, at
least you have a second o r w hatever to sit there and fill out your ch art and
I was ju s t felt like I w as a walking zom bie and everybody e lse ...I really
didn’t feel like I was supported at all, except for that one nurse th at was
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able to com e in and help me. Actually I had one nurse that came in, looked
at the baby and said, oh it’s looks like it could have been a cord
a cc id e n t-th a t's w hy it stinks in here, and left I d id n ’t even get a lunch
break that night. Not even five m inutes to go get a C oke because I w as
stuck in that delivery and everybody else w as real, real busy. Like I said
even the charge nurse who never has patients had two patients o f her
ow n it w as ju s t horrible and I felt like I had no support at all...A n d then
as soon as I got finished I had another patient waiting and I went and stuck
on som e m ore makeup and kept going. I m ean what else can you do and
th at’s w hy w hen I got home I ju st broke dow n. I ju st had nothing left to
give any m ore.
Fortunately for C laire she had supportive family at hom e that listened to her and
com forted her later. U nlike the stories o f her colleagues, C laire did not perceive working
in an environm ent w here supportive relationships w ith colleagues were available to ease
the tension o f being in this situation.
R elationships w ith women-clients were a potential source o f tension w hen the
nurses perceived the w om en as disem powered consum ers, blindly trusting the medical
m odel o f childbirth. Participants realized m ost w om en only knew about the m edical
m odel o f birth and had no knowledge o f other w ays to give birth. Frequently w om en in
their care did not ask questions about medical routines that w ere ordered. The participants
described their feelings o f frustration and disappointm ent w ith the women. The
participants w ished the women would be more responsible for themselves and their
births, som etim es failing to recognize the influential pow er that dom inant culture had on
w om en’s know ledge, choices and roles during childbirth. The participants offered
inform ation and attem pted to get the women involved in their care, but realized they had
to accept the w om en’s position and care for them w ithin this reality.
A m y w orked at a private institution w ith a relatively w ell-educated, m iddle class
population o f w om en. Y et she expressed frustration dealing w ith wom en from that
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population who came in for a labor induction without knowing anything about the
procedure or its risks,
Just w hat are your wishes for your birth? You know, what are you
expecting this to be like? What do you want it to be like? W hat d o n ’t you
w ant? That kind o f thing. But m ost ladies, I think are ju st really
uneducated as to w hat they’re going into. [They enter the unit] hi I ’m here
to be induced and put them in the bed, put them on the m onitor and they
ju st lay there and they d o n ’t ask questions. I tend to explain a lot, do you
know what y o u ’re here for? Do you know w hat this gel is going to do and
do you know w h at’s going to happen to you tom orrow ?.. .1 think it’s pretty
sad that they com e and don’t have any, they haven’t educated themselves.
T h ey ’re just going to let these physicians do w hat they d o .. .W ell you’re
here for that [induction] and you d id n ’t ask any questions, you d id n ’t go
look anything up? I think it’s really sad and it’s extrem ely com m on.
Participants w ho w orked in NICU areas and took care o f babies whose m others
were from a lower sociecom onic status and diverse backgrounds also faced the frustration
o f w orking w ith m others who displayed a lack o f responsibility o r interest in being
involved w ith the baby’s care. Vicky described how she worked w ith a m other to get her
to be involved with her baby. The m other had four other children w ith four different
fathers and had relinquished custody o f those children to the respective fathers. W ith the
fifth baby in NICU V icky recognized a need to work w ith this m other to promote
parenting skills and attachm ent,
W e all kind o f started promoting it [mother-baby relationship] w ith her.

Like alright, the history o f it’s not very good. So let’s see w hat w e can do
to get this m om involved with this baby., .if she w as in there w e w ould go
talk to the baby, talk with her and say, you w ant to hold the baby? And
ju st kind o f prom ote bonding with them and i f sh e’d say, no, no, h e ’s too
sick. [I replied] N o, it’s actually better for him and we w ould w rap the
baby up and kind o f push the situation along. It got to the p oint where she
w ould visit m ore frequently and now the baby is still with us, this has been
m onths now, she visits like every day and the d a d ’s very involved and I
m ean they love and kiss him, bonding beautifully with this baby. But it
took extra effort to push the situation along.
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Relationships w ith wom en who did not accept responsibility for them selves or
who did not em brace w om an-centered ideals were a constant tension for the participants.
The participants perceived it was more difficult to provide w om an-centered care when
w om en had health care values that differed from their own. The nurses exerted
them selves to present different perspectives to the wom en and w orked to m ake a
difference in their situations. Relationships with the w om en led participants to articulate a
range o f feelings from anger and frustration to a great sense o f satisfaction w hen they felt
they connected w ith the w om en and im proved the health care situation.
The tensions the participants faced seeking w om an-centered practice in the
current health care delivery system resulted from a conflict in values betw een their
w om an-centered philosophy o f childbirth and the technocratic m odel o f childbirth in
which they practiced (Davis-Floyd, 1992; 1996; Rothman, 1982). The m aternity
environm ents described by the participants were characteristic o f the technocratic model
o f childbirth.
The participants experienced tensions in their world o f practice because their
values o f w om an-centered care were in conflict with the values o f technocratic birth. The
w om an-centered value that birth occurs in its own tim e and should not be sped up
w ithout sound m edical indications was in conflict with the clinical practices the nurses
w ere confronted with everyday. The routine use o f pitocin, artificial rupture o f
m em branes, forceps, and episiotomies described by the participants w ere exam ples o f
how the m anipulation o f tim e contributed to the m edicalization o f birth (A m ey, 1982;
Rothman, 1982). Such routines continued to support the m etaphor o f the w om an’s body
as m achine and labor as a mechanical w ork that can be controlled to im prove efficiency
and productivity. Likew ise, other rituals o f practice, such as bedrest, IV, and continuous
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electronic m onitoring represented “a patterned, repetitive, and sym bolic enactm ent o f a
cultural belief or value" (Davis-FIoyd, 1992, p. 8). These birth rituals enacted the
dom inant belief system that science, technology, patriarchy, and institutions w ere
superior to nature and women, and were necessary' for birth. T he participants were
oriented to the m edicalized birth rituals as they were assim ilated into the cu ltu re o f
hospital m aternity care.
The participants were conscious o f how the system o f care was designed to co-opt
w om en’s access to inform ation o r w om an-centered birth alternatives (W orcester &
W hatley, 1988). M ary, the childbirth educator in this study described how the medical
establishm ent at the hospital dictated what w as taught in the classes. The participant was
prevented from discussing philosophies o f birth and birth planning. A lternatives to the
routine practices w ere only discussed as the consum ers had questions. A prenatal
education curriculum designed to avoid teaching all alternatives violated the legal
definition o f inform ed consent and limited the w om en’s autonom y in decision m aking
(Sherw in, 1998). Participants questioned w hat inform ation w om en used to consent to
induction o f labor o r epidural anesthesia w'hen they seem ed to b e uninform ed at times.
Participants described instances w here they believed w om en w ere offered choices for
convenience o f the caregiver, as opposed to m aking informed, autonom ous decisions.
The participants entered health care organizations designed by m asculine logic
w here pow er w'as em bedded in hierarchical system s (Davies, 1995). The nurses were
given limited pow er to make decisions o f care w ithout consulting the physician. W omen
who requested options considered in conflict w ith the medical routines required physician
approval. The nurses perceived th eir hands w ere tied at tim es d u e to the requirem ent to
follow the routine m edical orders that the doctors and the w om en had agreed upon. The
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participants described their w illingness get the routine orders changed when called upon
by the w om an. They looked for opportunities to make a difference in w om en’s
experiences in the instances w here they had control to do so. The participants recognized
their place in the hierarchy o f the institution and as relatively new graduates they were
som etim es reluctant to challenge authority.
The im personal nature o f the high volum e, busy w ork areas was described as
being a challenge to w om an-centered care. The participants’ stories illum inated how
m aternity nursing was often reduced to a series o f steps that involved follow ing medical
protocols and controlling the tim e o f birth (C heek & G ibson, 1996; D oering, 1992). The
busy environm ents w here protocols and time fram es were prim ary often reduced the
w om en to “objects” to be controlled and m anipulated, rather than subjects to be
understood and known. The m edically-focused environm ents m ade it more difficult to
establish relationships with w om en and/or clients that w ere at the heart o f w om an-
centered care. The frustrations verbalized by participants w ere consistent w ith the work
stressors m ore experienced m aternity nurses have identified (Diam ond, 1996). The
participants who described having supportive nursing peers, preceptors, and m anagers
seem ed to cope better with the stresses o f practice. A ccording to Benner et al. (1996)
clinical know ledge is socially em bedded and therefore developm ent o f the n ew nurse was
dependent upon support and m entoring by the nursing com m unity.
From a fem inist-postm odern perspective, the participants in this study were
conscious o f the oppressive nature o f the health care system. T heir study o f w om an-
centered m aternity care in nursing school opened them to the possibility o f w om en
having m any alternatives for birth. Issues o f w o m en ’s rights and autonom y w ere
illum inated by reading birth stories o f women w ho made decisions about th eir care based
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not only on medical science but on know ledge handed dow n by other women who had
given birth. The possibilities o f spiritual awareness and holistic care w ere present. A s the
participants entered the health care system as nursing students and later as nurses, they
recognized how w om en’s experiences w ere dictated and controlled by the routine use o f
medical interventions.
The participants in this study w elcom ed the w om en who entered the medical
environm ents with birth plans or goals for natural o r w om an-centered birth. U nlike som e
o f their co-workers, the participants appreciated and understood the w om en’s perspective
and were not afraid o r unwilling to care for them in a different paradigm . Likew ise the
participants also attem pted to provide woman-centered care in the m edical m odel, w ithin
the restraints imposed. In those situations the nurses were aw are o f the pow er issues and
negotiated care accordingly. These participants w ere able to m ake space for both
paradigm s o f care as a result o f their education and increased consciousness o f w om en’s
experiences.
However, undergoing conflicts and tensions betw een their values and w hat they
saw in practice was stressful for the participants. They displayed strong senses o f m oral
agency seeking to see women cared for in respectful, caring ways. T hey saw choices and
consequences o f actions taken in clinical situations that concerned them . Benner et al.
(1996) described the “competent nurses’ sense o f agency” (p. 92) as being a source o f
reflection and conflict. At this stage o f developm ent B enner et al. (1996) believed
com petent nurses experienced discom fort in clinical situations and recognized how they
can influence clinical decision making. The choices or alternative o f care and the
consequences became more visible to them. The participants in this study displayed such
a level o f concern for their actions involving w om en’s care.
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The participants’ act o f telling stories o f practice that exposed oppressive care
situations can be considered a form o f resistance to the oppressive childbirth practices in
w hich they observed or took part in. S im ilar to fem inist critiques o f childbearing b y
sociologists, nurses, anthropologists, and childbearing w om en, these nurse p articipants’
stories also exposed the pow er o f dom inant discourse to define childbirth experiences
(A rm s, 1994; D winell, 1992; Martin, 1992; Rothm an, 1982, 1989; Sandelow ski, 1981).
The nurses in the study offered additional insight into the pow er relationships in the
health care system that impacts nurses’ abilities to intervene in w om an-centered w ays.
T heir descriptions o f practice exposed the social transform ation required at many levels
to change the current m atem al-new bom culture. The situational variables o f practice that
either facilitated or im peded w om an-centered nurses’ ability to provide hum anistic care
w ere illum inated. The forms o f power displayed in the participants’ stories that inherently
controlled nurses’ and w om en’s choices can be articulated through F oucault’s notion o f
pow er.
Foucault’s (1977/1980) theory o f biopow er, as the effort o f science to study and
regulate hum ans, was present within the participants’ stories o f clinical practice.
A ccording to Foucault’s theory, the culture o f W estern birth practices described by the
participants o f this study, resulted from the authority and status granted twentieth century
techno-scientific medical discourse concerning childbirth. Em bedded in the participants’
stories is a com plex web o f pow er relationships that w orked to m aintain W estern m edical
discourse as the accepted “truth.”
As dem onstrated through the participants’ descriptions o f practice, society
accepted the preem inent authority o f m edical experts over the m idw ife’s o r w om an’s
know ledge o f birth. W omen looked to the medical profession to help them give birth,
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based on the b elief that the techno-scientific discourse w as the truth. C onsistent w ith the
participants’ experiences, the m odem professional nurse was expected to conform to and
support the medical discourse, follow orders and assist w ith care o f m edical procedures
such as episiotom ies, forceps deliveries, and pitocin inductions. These procedures, in
turn, were disciplinary techniques that m anipulated tim e, controlled the unpredictable
natural process, and transform ed birth to a medical event. As described in this study,
even the discourse o f childbirth education evolved into teaching women to expect
com m on m edical procedures.
Sociologist, A m ey (1982) believed it was the pow er o f techno-scientific
discourses that transform ed tw entieth century obstetrics from a period o f confinem ent to
a period o f surveillance and m onitoring. Surveillance o f w om en and babies w ith m onitors
becam e a form o f power that controlled com fort m easures, movement o f w om en’s bodies
and childbirth choices (Foucault, 1975/1977). The participants in this study reported the
continuous attachment o f the w om an to a mechanical m onitor and the com m on u se o f
labor induction and epidural anesthesia. These routine procedures often prohibited m any
options for w om an-centered childbirth. O nly the physician had the pow er to allow th e
w om an’s body to move about o r to cease the constant mechanical observation. T he
nurses reported being legally restrained from making decisions about w o m en ’s care, such
as m ovem ent, because o f the pow er o f the medical order and the risks associated w ith
confronting physicians they perceived w ere powerful and disinterested in a collaborative
relationship w ith a nurse o r wom an-client.
The participants recognized the w ays these pow er relationships affected w o m e n ’s
know ledge and choices for birth, and ultim ately their experiences. The participants
recognized conflict felt betw een w hat they thought “ought-to-be” verses w hat they
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observed in practice. This was a tension that they lived through in everyday practice. The
nurses in the study negotiated the pow er relationships finding som e spaces to alter the
situations o f care when possible. Finding w ays to negotiate the system to provide wom an-
centered care and to shift more pow er to w om en to make inform ed choices w ere ongoing
challenges for the relatively new graduate.
The participants were educated in m edical and w om an-centered m odels o f care
and sought to practice woman-centered care as the ideal for practice. Due to th eir
consciousness and education they were able to recognize the distinctions o f the m edical
m odel that controlled w om en’s experiences. The participants experienced conflicts in
care surrounding tim e, choices, rituals, and the use o f m edical information to protect the
culture. They negotiated their roles as nurses w ithin know ledge and values in w om an-
centered care, w hile trying to conform to expectations in a technocratic system .
Sum m ary
In this chapter I presented a description o f the participants and reported the
findings o f the study. The participants’ experiences in w om an-centered m aternity nursing
education and practice were analyzed using H eideggerian herm eneutical research m ethod
and further interpreted through a fem inist-postm odern lens. Three constitutive patterns
em erged from the data analysis: Otherness, B eing and Becom ing a W om an-Centered
N urse, and Tensions in Practicing W om an-Centered Care. The constitutive patterns and
relational themes w ere described. Excerpts from the participants’ interview texts were
presented to support the analysis and interpretation o f the findings.
CH A PTER VI
C O N C LU SIO N S AND RECO M M EN D A TIO NS
In this study, I described the shared practices and com m on m eanings revealed
through the narratives o f nineteen new graduates practicing m aternity nursing subsequent
to being taught a w om an-centered philosophy o f care in a baccalaureate m aternity
nursing course. Nineteen m atem al-new bom nurses betw een the ages o f 23 and 43 w ho
had been in practice from betw een six m onths and three years were interview ed. The
interviews w ere analyzed using th e H eideggerian herm eneutical m ethod described by
D iekelm an and A llen (1989) and through the lenses o f fem inist-postm odern theories.
From analysis o f the interview texts, three constitutive patterns were identified. The
patterns were Otherness, Being a n d Becom ing a W oman-Centered N urse, and Tensions
in Practicing W oman-Centered C are.
In this chapter I discuss th e conclusions related to the patterns and the relational
themes. W ithin this discussion I review my assumptions w hich are relevant to the
findings o f this study. Finally, I m ake recom m endations for nursing education, practice,
and research.
C onclusions and Discussion
The m eaning o f the new graduates’ clinical experiences in m aternity nursing
subsequent to studying m aternity nursing from a feminist perspective in their
undergraduate nursing course w a s revealed through the findings o f this study. The
findings indicated that the new graduates embraced and sought to im plem ent aspects o f a
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philosophy o f woman-centered care in practice. T he descriptions o f w hat it meant to be a
nurse w ith the know ledge o f w om an-centered care w as m ade explicit through the new
graduates’ descriptions o f clinical practice. The m eaning o f a w om an-centered
philosophy o f care was described as the new graduates recalled practicing according to
their values and believing they w ere m aking a difference in w om en’s care. Likew ise they
described the m eaning o f not being able to practice w ithin a w om an-centered philosophy.
The nurses’ struggles w ith the barriers to w om an-centered care revealed what it m eant for
them to either cope w ith or overcom e obstacles to being w om an-centered.
The conclusions o f this study are discussed w ithin the follow ing summaries:
“Creators o f W oman-Centered C are,’’ “Barriers to Practicing W om an-Centered C are,”
“A dvocacy as W om an-Centered C are,” “Facilitators to Practicing W om an-Centered
Care,” and “ Resistance to Fem inist-Postm odern Pedagogy.”
Creators o f W om an-Centered Care
M aternity nursing education that teaches a w om an-centered philosophy o f care,
imbued w ith feminist pedagogy, can transform n u rses’ practices w ith childbearing
women. The new graduates in the study acknow ledged that learning w om an-centered
m aternity nursing w ithin their undergraduate education was instrum ental to their
aw'areness o f w om en’s oppressions in m aternity care and to the possibilities o f a w om an-
centered model o f care. They view ed m aternity nursing w ithin the w om an-centered
framework introduced to them in th eir m aternity nursing course. In turn, their internalized
values o f a w om an-centered philosophy facilitated an aw areness o f w o m en ’s needs and
opened possibilities for im proving care.
The nurses in the study articulated view points about birth and w om en that w ere
based on a w om an-centered philosophy. They described their clinical experiences w ith
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w om en around the ideologies o f power, control, choices, and em pow erm ent. The stories
o f practice shared by nurses in this study revealed that they view ed and critiqued care
w ithin a critical fem inist perspective. They were conscious o f childbirth practices that
w ere oppressive to w om en and w ere aware o f other possibilities o f care that they believed
could im prove services. A fem inist critical lens provided the n u rses’ in this study w ith the
know ledge to describe sites o f oppression and deconstruct how dom inant practices
influenced childbirth experiences. As the nurses developed professionally and learned the
dom inant system , they w ere positioned to advocate for w om en’s rights in specific
situations.
T he nurses described their impact on the health care delivery system and w o m en ’s
experiences through their actions o f involvement and advocacy w ith w om en in their care.
A dvocacy actions by the new graduates represented resistance to patriarchal traditions in
m aternity practice. Practices such as choosing the tim e, place, and position o f birth, for
the convenience o f the caregiver, rather than for the best interest o f the woman w ere
challenged by nurses in this study. Institutionalized routines that interfered with the
m other-infant relationship w ere modified. The new graduates did no t view their role as
protector o f the status quo, rather they were constantly looking fo r w ays to individualize
and im prove care. O bstetrical procedures and interventions were evaluated according to
the context o f the situation and the way the procedure affected the outcom es and
experiences o f w om en and babies. The nurses in the study felt discom fort when w o m en ’s
rights w ere violated and sought to change practices w hen they could.
U nlike m any o f their colleagues, the nurses in this study reported being
com fortable and delighted about caring for a woman w ho entered th e health care system
w ith a birth plan o r a dem and for a woman-centered experience. S tu d y findings indicated
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the new graduates connected well w ith w om en wanting a w om an-centered birth. They
understood why the women wanted input into their birth choices and w ere w illing to
facilitate requests. The nurses had know ledge about com fort m easures for natural birth
and understood the nurse’s role w ith partners and doulas.
Sensitive and em powering interpersonal relationships w ith w om en resulted from a
woman-centered approach to care. The nurses in this study described m eaningful
relationships with women w ithin short and long-term situations. As they developed
relationships, the nurses w ere sensitive to the m ultiple m eanings o f childbirth to women
across diverse social circumstances and cultures. Instances o f gender sensitive care,
advocacy, and empowerment strategies w ere evidence o f the nurses’ abilities to connect
w ith women, m ake a positive difference, and resist patriarchal traditions if the woman so
desired. It was through these relationships w ith women that nurses in the study described
being rewarded for their concern. The nurses described positive reactions from women
w hich included women asking for them by name, com ing back to visit them on the unit
w ith the baby, verbally thanking them, and sending letters o f appreciation. W omen often
confided in the nurses their personal concerns and asked the nurses their opinions about
issues.
The woman-centered practices revealed in this study indicated that nurses’ values
o f w om an-centered care can be internalized o r further strengthened by experiences with
feminist pedagogy in a m aternity course. Fem inist values o f m aternity care taught in
nursing school can be sustained over a period time to influence new graduates’
perspectives and practices. Nurses in this study, however, revealed struggles with
practicing woman-centered care in all situations. Contextual circum stances impeded their
abilities to be woman-centered caregivers.
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Barriers to Practicing W om an-Centered Care
I conclude there w ere barriers to practicing w om an-centered care based on the
pow er issues in the health care delivery system , professional developm ent o f the new
graduate, the context o f the clinical situation, the highly m edical environm ent that
controlled w om en’s choices, staffing issues, and the lack o f m entors. T he barriers to
w om an-centered care presented as tensions in practice that the nurses in the study had to
either cope w ith o r confront and try to change. They coped w ith their com plicity in
sustaining a medical m odel o f practice when the barrier could not be changed. W hen
situations could not be changed, it was because the new graduate perceived it was too
risky to m ake suggestions to the physician o r the w om an, o r else they d id not have tim e
o r opportunity to advocate in the situation.
In situations w here nurses could not confront and change the barriers, they lived
w ith an internal struggle o f knowing they w ere contributing to m edically-focused birth.
In these instances, the nurses in the study fulfilled the expected nursing care and sought
to connect w ith the w om an and provide hum anistic care w ithin the m edically controlled
situation. The nurses in this study were able to practice w ithin the m edical m odel and
perform nursing care that supported the medical goals. T hey did this, how ever, know ing
that w om en’s experiences were being affected by m edical decisions.
The nurses in the study verbalized frustration and anger when the m edical m odel
violated w om en’s rights, but they realized the system is designed to em pow er physicians.
The nurses felt they som etim es had no option but to follow reasonable orders, such as to
increase pitocin or assist doctors to use forceps when requested. They believed choices
such as these inherently belonged to the physician. But they disagreed w ith physicians’
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decisions w hen they believed the interventions w ere chosen to speed up the tim e o f labor
for the convenience o f the physician and w ere not in the w om an’s best interest.
M any barriers represented patriarchal traditions embedded in the health care
delivery system . N urses’ aw areness o f barriers dem onstrated their consciousness o f ways
the health care system defines and limits w om en’s experiences and nurses’ practices.
Physician relationships, staffing and w ork dem ands, and the pow er o f the p h y sician ’s
orders were factors in the health care system that sustained patriarchal traditions and held
“ pow er over” the nurses’ abilities to deliver w om an-centered care. The individual nurses
in this study perceived them selves being lim ited in th eir abilities to overcom e th e se
traditions.
The nurses in this study recognized how w om en and their childbirth experiences
continued to be controlled by the p ow er o f m edical discourse that prescribed m edical
interventions, often w ithout the w om an’s inform ed consent. In m any cases, the inherent
pow er o f m edical discourse caused w om en to value the physician’s opinion, an d women
them selves saw no need to seek inform ation. W omen trusted the m edical discourse and
w anted the physician to deliver their babies and elim inate much o f the pain. T he
sophisticated use o f verbal coercion by physicians was noted by the nurses in th e study as
a com m on m ethod used to influence w om en to choose procedures, such as induction o f
labor and epidural anesthesia. The health care delivery system in w hich the nurses
w orked was so accustom ed to the care o f w om en w ithin the m edical model, th at the
nurses in the study found other sta ff m em bers lacked the understanding and caring
m easures necessary to support w om en in natural childbirth. One childbirth educator in
the study described how childbirth education classes were designed to protect th e medical
m odel o f care rather than to teach birth planning from multiple alternatives.
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T he new graduates’ need for developm ent o f nursing practice skills was
considered a barrier to the participants developing as w om an-centered caregivers in
m edically focused environments. T he new graduates in this study w ere learning to apply
their know ledge o f w om an-centered care at the sam e tim e they were developing o th er
nursing com petencies in practice. T hey felt pressured to become functional in the
expected routine practices and organizational tim e frames valued by the institution. T he
new graduates recognized the need to be proficient in skills, such as interpreting fetal
m onitoring, newbom suctioning, and physical assessm ent, in order to provide safe and
com petent care. C linical situations involving high-risk pregnancy and new bom care and
em ergency contingencies required continued learning.
The nurses in this study recognized the need to m aster these skills and understand
the clinical importance o f the routines o f practice prior to challenging the routines o r
advocating for alternative options consistent w ith woman-centered care. They had to
leam under what circum stances the routine could be challenged and w hat the risks m ight
be. The skill o f involvem ent that w as described as key to w om an-centered practice
required refinem ent and practice, especially in situations involving crisis or perinatal
death. T heir level o f involvem ent, from providing sensitive, individualized care to actions
o f advocacy and em pow erm ent, w as dependent upon the new nurses’ professional
developm ent and the context o f the clinical situation. The study findings revealed the
developm ental process to being and becom ing w om an-centered nurses in practice w as
com plicated by the new graduate's need for continued developm ent in all nursing
practice skills. Only through time and clinical practice did this factor becom e a less
significant barrier to the nurses being wom an-centered.
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The context o f clinical practice situations was an equally complex b arrier to
w om an-centered practice that w as described by the nurses in this study. F irst, the nurses
needed tim e and opportunity to establish relationships with w om en and c o m e to know
what w om en wanted done differently in their care. Knowing w hat wom en w anted worked
well for the nurses when wom en cam e in with birth plans o r verbalized desires. In these
situations the nurses sought to deliver care according to the birth plan o r called the
w om an’s physician to advocate for the w om en’s wishes. B ut in situations w h ere the
wom an arrived w ith medical orders that specified routine care and the w o m an voiced no
preferences, the nurses believed they must c a n y out the orders.
T he pow er o f the dom inant medical culture to control w om en’s know ledge and
acceptance o f birth alternatives and limit m aternity nursing practices was recognized as a
barrier to nurses in the study being woman-centered. The nurses realized the dom inant
culture o f m edicalized birth pre-determined routine care and limited the boundaries o f
their practices. The nurses realized that many w om en had no knowledge o f alternatives
and lim ited inform ation about choices they m ade with their physicians. In instances
w here w om en perceived they had made “inform ed” choices w ith their physicians, the
nurses felt com pelled to carry out the specified interventions. The nurses im plem ented
the orders w ith concern, educated women about what was happening, and attem pted to
provide sensitive care within the context o f the situation.
The context o f the health care delivery system in w hich the nurses in th is study
worked w as considered a prim ary barrier to w hether or not they would challenge a
practice o r suggest alternative care. The power o f physicians and medical discourse was a
challenge to the nurses’ willingness or ability to advocate for wom en and babies. As
participants learned the skill o f com municating w ith physicians, they learned w hich
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physicians were m ore collaborative. The nurses w ere m ore likely to call physicians and
advocate for p atients’ wishes w hen the physician had a reputation for offering patients
choices, and being open to nurses’ suggestions.
The nurses in the study considered the m edicalized environm ent o f m aternity care
a barrier. Because o f the com m on use o f m edical interventions and constant surveillance
for problem s, a philosophy o f high-risk care perm eated the m aternity practice areas. The
nurses at larger referral hospitals took care o f high-risk w om en and babies w here m edical
interventions for obstetrical and new bom com plications w ere indicated. This em phasis on
high-risk care w as a barrier to nurses m aintaining th eir perspective o f norm alcy w ith low
risk wom en.
T he nurses in this study had m inim al exposure to advanced practice nurses and
m idw ives in practice, therefore the issue o f m idw ifery care rarely em erged in the
interview s. Only tw o nurses in the study reported w orking w ith m idw ives and those
experiences were lim ited. The lack o f opportunity to w ork w ithin a m idw ifery m odel o f
care prevented the nurses in the study from being further sensitized to the possibilities o f
m idw ifery care. N o new graduates reported interest in seeking m idw ifery education at
this tim e in their developm ent. Few new graduates in this study voiced readiness to
continue formal education and thus had not considered the m idw ifery role as an option.
One nurse, however, w as in graduate school in a fam ily nurse practitioner program .
Staffing assignm ents in acute care settings w ere often considered a barrier to
nurses in this study practicing w om an-centered care. Even as the new graduate gained
organizational skills, staffing rem ained problem atic. The num ber o f patients and
com plexity o f situations often increased as the nurses becam e m ore proficient w ith
routine care. The scheduling o f procedures, such as labor inductions, often increased the
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nursing care responsibilities. Staffing assignm ents often prevented the nurses from
feeling they could get to know women well enough o r have the time to individualize their
care. The nurses in this study adapted and coped with the staffing barriers in various
ways, often sw itching shifts and changing clinical units to find a pace and level o f
responsibility they could accept. The nurses adapted to individual situations and
attempted to deliver the best care they believed possible, w hile knowing barriers
prevented certain care alternatives.
Lack o f nursing m anagem ent support for changing the conditions o f practice and
lack o f w om an-centered professional role-models were also barriers to the nurses in this
study being able to practice w om an-centered care. The hospital m aternity units were
overw helm ingly m edically-focused, therefore, many o f the nurses w ho m entored them
did not dem onstrate w om an-centered values or offer role-m odeling for learning the skills
o f advocacy specific to providing woman-centered care. A perceived lack o f support
from other colleagues o r m anagers contributed to the tensions o f practice.
A dvocacy as W oman-Centered Care
Being a w om an-centered maternity nurse in the health care system , as described
by nurses in this study, required continued developm ent in the skills o f advocacy and
empowerment. Since the m aternity nursing environm ents w ere not inherently w om an-
centered, the nurses in this study were required to constantly negotiate system barriers to
practice within a w om an-centered philosophy. Nursing resistance to the patriarchal m odel
o f m edicalized birth w as m ost evident in situations w ere advocacy and em pow erm ent-
building skills w ere used by individual nurses to confront issues o f injustice o r educate
w om en about alternatives. T he nurses’ stories that centered on advocacy resulted in the
w om en’s experiences being changed or their dignity and rights being protected. N urses in
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this study were enabled through their knowledge o f w om an-centered care to change
practices, to offer inform ation, and to support the em pow erm ent o f wom en to m ake
choices for themselves.
The nurses in the study sought opportunities to advocate for w om en and o v er
com e the barriers w hen possible. They recognized those situations that could not be
changed and coped by providing appropriate care w ithin the m edical situation. N urses
who chose to take action realized that their advocacy actions and the inform ation given
w om en could be interpreted as going over the “boundary” for nursing. The nurses
assum ed risk for this happening, based on the context o f the situation and the particular
physician involved. The nurses were required to carefully negotiate barriers, based on the
context o f the situation.
Yet, the barriers to w om an-centered practice often left the nurses unable to put
their concerns into action. N ot all nurses were able to confront physicians o r speak up and
validate the w om an’s wishes in all situations. Further professional developm ent and
professional support within the health care system w ere needed. The participants w anted
to advocate and recognized the need to, but at this stage o f their developm ent were still
having difficulty negotiating the system or feeling confident in their role to advocate in
highly m edically-focused environments. Continued developm ent o f advocacy and
em pow erm ent-building skills rem ained a need for nurses in this study to create w om an-
centered care in m edically-focused environments.
Facilitators to Practicing W om an-Centered Care
W om an-centered m aternity nursing education, new graduate orientation, nursing
experience, a supportive nursing environment, and professional relationships with others
seem ed to be im portant to the nurses for developing strategies to provide wom an-
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centered care in highly m edicalized m aternity and new bom settings. The educational and
life experiences o f the new graduates made them conscious o f the health care conditions
that required change o r im provem ent in w om en’s care. They articulated a philosophy o f
woman-centeredness and sought to em body aspects o f the philosophy in practice, because
o f their education, and internalized values.
Further professional developm ent was required to enable the new graduates
educated in w om an-centered care to practice w ithin this philosophy. C ontinued
professional developm ent provided experiential learning necessary for the new graduate
to understand the context o f the clin ical situation and know w hen other options w ould
benefit the woman. W hen nurses in th e study described situations where they intervened
to provide wom an-centered care, th e y described the details o f th e clinical situation and
w hat they had to do to challenge the system . It was evident they understood the culture o f
the clinical setting and felt com fortable with the routine practices expected o f a registered
nurse in the situation. This know ledge and confidence that w as developed through new
graduate orientation and clinical practice was key to the nurses being w illing to offer and
support alternatives.
The new graduates in the stu d y who described w om an-centered care situations
dem onstrated they had learned how to com m unicate and connect w ith w om en and their
families. These skills required continued developm ent as the nurses had the opportunity
to care for women in diverse situations. The developm ent o f interpersonal skills and the
increasing confidence in their abilities as nurses facilitated their ability to “take charge”
and seek to change w o m en ’s experiences or confront other health care professionals.
Findings o f this study indicated that supportive relationships and m entors helped
new graduates deal w ith the tensions o f practice and learn socially em bedded skills
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necessary to gain confidence in their nursing care and advocacy skills. N ew graduates in
this study identified their relationships w ith other health care professionals, peers and
nurse m anagers as being prim ary to how well they dealt w ith the tensions o f practice. The
nurses described ways m entors helped them get through difficult situations, such as
perinatal death, em ergency care, o r confronting a physician. A few nurses reported
w orking w ith a w om an-centered colleague or m anager that served as a role m odel for
being w om an-centered in m edically-focused settings. T he nurses w ho described working
with w om an-centered role m odels believed they were supported in th eir efforts to
practice w om an-centered care. Likewise, w orking with physicians w ho w ere w illing to
listen to nurses’ suggestions and w ere opened to alternative care options facilitated the
new graduate’s ability to be w om an-centered. W orking w ith physicians w ho w ere known
to be collaborative with nurses and their patients facilitated the n u rses’ w illingness to
pursue care alternatives.
T he w om an’s articulated desire for childbirth choices and a w om an-centered birth
facilitated the nurses’ efforts to provide w om an-centered care and advocate on h er behalf.
The nurses described being m uch m ore com fortable confronting o r calling a physician
when the w om an verbalized her special requests or had a birth plan. T he nurses w ere
w illing to conform to w om en’s requests w ithin the param eters allow ed by the physician
and the institution.
R esistance to Fem inist-Postm odern Pedagogy
Student nurse resistance to fem inist-postmodern pedagogies reflected the values
o f a m odem , technocratic educational system that values science, technology, and
m edicine over w om en and families, nature, and nursing (D avis-Floyd, 1992; Doll, 1993).
The findings o f this study revealed that, unlike the new graduates in this study, m any
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other students did not com e to value the women-centered philosophy or the fem inist
pedagogy that characterized the m aternity nursing course. The new graduates in this
study described their experience in the maternity course as an experience o f being other.
T hey described a strong connection to the course, but believed m any other peers did not
“get it” and resisted or rejected both the ideology and stm cture o f the course.
A common com plaint the new graduates rem em bered peers m aking about the
course w as that it was “too touchy-feely” and “too easy.” B ecause the class form at did
not include lecture, and tests w ere som etim es a take home form at, the nurses in the study
rem em bered peers m aking assertions that they w ere not learning anything. A lthough the
nurses in the study rem em bered having to adjust to the differences o f the course, they
eventually came to accept new w ays o f learning nursing and found m eaning in the
philosophy and structure o f the course. The nurses in the study em braced the birth stories
that accom panied the nursing textbook and found journaling w ith faculty about clinical
experiences helpful.
Based on the findings o f th e study, it seemed the nursing students w ho resisted the
m aternity nursing course did so because it was different from the technocratic nursing
curriculum with which they w ere accustom ed. U nlike a curriculum based on technocratic
values, the w om an-centered m aternity course provided spaces fo r multiple perspectives
and diverse voices. Em pirical know ledge, considered prim ary fo r a technocratic
educational system, was decentered by giving space for know ledge from n u rses’ and
w om en’s lived experiences with childbirth care. The dom inant m edical interventions and
nursing care that supported those interventions in hospital births w ere contrasted w ith the
w om an-centered m odels o f care and the nursing intervention that facilitated w om an-
centered birth in diverse settings. T eaching strategies were purposely designed to connect
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students to the ethical concerns o f caring for w om en and to have them become
consciously aware o f childbirth and inform ed consent issues.
According to the nurses in the study, their peers who rejected the course believed
the technocratic m odel o f care w as m ore im portant for nurses to know and they w anted
m ore emphasis and class time to be spent on that perspective. The nurses in the study
believed some o f their peers did not think they learned enough about the technocratic
model o f birth. In turn, w om an-centered ideology was less valued o r else fully rejected by
the student resisters as a way to view w om en and childbirth in W estern culture.
W hat enabled the new graduates in this study to be open to the m aternity course
and w illing to accept an alternative pedagogy, w hile other students rejected it, cannot be
fully understood through the findings o f this study. The new graduates in this study
reported why they believed students resisted the structure and philosophy o f the course.
T hese reasons included the patriarchal culture o f the comm unity and the nursing school, a
younger age group, and the highly structured environm ent o f higher education.
A ssum ptions
As I conducted this study and interpreted research data I did so with aw areness o f
my personal beliefs and values surrounding m aternity nursing, nursing education,
childbearing women, and the health care delivery system. In this section the assum ptions
upon w hich I conducted the study are reviewed and analyzed based on the study findings.
Additional assum ptions that I identified while conducting the study are presented and
discussed. The assum ptions I had identified before beginning the study were as follows:
1. The m aternity experience is a powerful event in the lives o f women. W hether the
experience is perceived positively o r negatively, it greatly affects w om en’s psyches. This
assum ption was supported by the findings o f this study. According to the participants,
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unnecessary procedures, obstetrical time m anagem ent, and the environm ent o f care
directly affected w om en’s experiences and perceptions o f the birth experience. A lthough
the stories were told through the nurses’ perspective, the descriptions o f w om en’s
experiences indicated the im portance o f both physical and m ental health perspectives.
T he diversity o f w om en’s experiences illum inated the reality that there is no one ideal
birth event nor are all births happy occasions for w om en. In childbirth situations
involving rape and fetal demise, special interventions w ere necessary to assist w om en to
cope with and find meaning in th eir experiences.
2. The m aternity experience and reproductive options in W estern culture are socially
constructed around a m edicalized dom inant discourse that protects the interests o f the
patriarchy, i.e., m en, religion, science, and the heterosexual lifestyle. This assum ption
was supported by the findings o f this study. T he nurses’ descriptions o f practice in the
study confirm ed that the hierarchal power o f physicians, m edical control o f childbirth
education, and routine medical orders, were am ong the barriers to w om an-centered care
em bedded in dom inant discourse that protected the interests o f patriarchal m odels o f care.
It was through the dom inant m edical discourses o f birth and science that w om en’s
choices were often defined and limited. The nurses in this study described how the
inherent pow er granted the m edical order dictated birth tim es and circum stances,
depending on the philosophy o f the physician. C hildbearing outside o f m arried,
heterosexual couples was often described as problem atic for som e caregivers and clinical
settings. Nurses in the study described situations where poor, single, adolescent w om en
o r lesbians were often m arginalized by other nurses or physicians that could no t accept
this diversity in childbearing.
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3. Each w om an attaches a unique, personal m eaning to childbearing. Each woman
experiences reproductive transitions w ithin the context o f her life circum stance. This
assum ption w as supported by the findings o f the study. A lthough w om en’s perspectives
w ere not articulated in this study, the n u rses’ stories illum inated the personal m eanings o f
birth and new bom care w ithin diverse social circum stances. T he nurses in this study
sought to understand the m eaning the birth experience had for each woman. T hey tried to
individualize care based on cultural and social circum stances. The nurses believed that
only through becom ing involved with w om en and know ing the context o f the w om an’s
situation w as w om an-centered care possible. O n the other hand, they also accepted
w om en w ho preferred a paternalistic relationship w ith health care providers o r a
m edically-focused birth experience. In these cases the nurses provided hum anistic care
and educated w om en on rationales for the m edical care know ing w om an-centered
interventions w ere limited.
4. H ealthy w om en are able to give birth w ith m inim al m edical intervention, with
know ledge o f alternatives and appropriate support. This assum ption was supported by the
findings o f the study. The participants’ stories described how they supported w om en in
situations that w ere considered totally “w om an-centered.” C linical situations w ere
described in the study w here w om en chose the hospital setting as their birth place, but
m anaged to give birth w ithout medical control o r routine interventions.
5. There are diverse w ays to experience birth w ith o r w ithout technological and
medical interventions. This assum ption w as supported by the findings o f the study. The
participants recalled situations o f care w ith and w ithout technological or m edical
intervention. The participants reported the use o f technology that was life saving and
necessary for the m other o r new bom or w as requested by the individual w om en. O n the
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other hand, this study also confirm ed that participants cared for women w ho chose
m inim al intervention and technology in natural birth situations. However, the possibilities
o f other form s o f diversity for birth such as m idw ifery attended births o r home birth
settings w ere not supported by the findings o f the study. Participants in this study had
lim ited exposure to these types o f diversity in childbirth care thus this study cannot
substantiate these possibilities.
6. N ovice nursing students can leam the m edical m odel o f childbirth, while
sim ultaneously critiquing it. This assum ption w as supported by the findings o f this study.
T he new graduates in the study recalled instances where the theoretical learning o f
w om an-centered care opened their eyes to see the injustices o f w om en’s experiences in
the health care delivery system. This aw areness occurred at the same tim e the new
graduates rem em bered learning m edically focused care in com m unity and acute care
settings in the maternity course. This evidence o f raised consciousness w as later
transferred to the participants’ practices as registered nurses as described in their stories.
7. N ovice nursing students are capable o f evaluating w om en’s experiences for
indicators o f the presence, or absence, o f a w om an-centered philosophy. This assum ption
w as supported by the study findings. The new graduates remem bered being in different
clinical settings where they were aw are o f the philosophical differences in w om en’s care.
M edically-focused ideology was contrasted w ith woman-centered ideology am ong the
settings and the caregivers working in them . The new graduates’ descriptions o f practice
likew ise indicated this skill was further refined in practice. Fine distinctions in w om an-
centered care could be described and analyzed by the nurses in practice situations.
8. Fem inist-critical pedagogy provides an opening from which nursing students can
com e to know w hat “ought to be,” based on their raised social consciousness. This
assum ption was supported by the findings o f the study. This was evident from the new
graduates w ho recalled their experiences in w om an-centered maternity nursing education.
Findings indicated that the raised social consciousness the nurses reported from
experiences in the maternity course was later transferred to practice. Participants
articulated being opened to another view o f w om en and childbirth outside a medical
model o f care. The participants described being sensitized to issues o f pow er and control
concerning w om en’s choices in childbirth as a result o f the m aternity nursing course.
Their raised consciousness that resulted from learning m aternity care w ithin feminist and
postm odern theories resulted in their ability to identify sites o f oppression in practice.
9. Students attain values in nursing school that are refined in practice, yet continue
to influence how a nurse practices. This assum ption was supported by the findings o f the
study. M y assum ption that the values students attained in nursing school w ere refined in
practice and would continue to influence how nurses practice was supported by the
findings o f the study. The new graduates in this study articulated ways they embodied
aspects o f w om an-centered philosophy in their practices. As the nurses continued to
develop professionally within the context o f practice settings, they eventually found
avenues w here women-centered care could be implemented. Likewise their awareness o f
the barriers to being woman-centered sparked their developm ent o f advocacy strategies to
m ake a difference in w om en’s care. The nurses’ initial learning o f a wom an-centered
philosophy o f care continued to undergo refinem ent as they learned how the philosophy
fit into their w orlds o f practice.
10. Each individual nurse is responsible for the nursing care she/he renders to an
individual patient. This assumption was supported by the findings o f the study.
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The assum ption that each individual nurse was responsible for the nursing care she/he
rendered to an individual patient was supported through the nurses’ senses o f agency and
concern expressed in their stories o f practice. The nurses in the study expressed concern
for their com plicity in supporting medical interventions w hen they did not believe the
intervention w as based on sound medical indication o r client request. As a developm ental
process, the new graduates learned the expected course for w om en o r new bom care and
looked for w ays to anticipate needs and plan future care that w ould be sensitive to the
w om en. T he nurses accepted responsibility for the care they gave and their decisions
regarding nursing advocacy.
11. N ursing education goes beyond educating for clinical health care o f hum ans. The
nursing profession is obligated to educate the student to live in the w orld consciously
aw are o f the cultural, political, and social variables that have global and individual effects
on health. T his assum ption w as supported by the findings o f the study. The need to
educate nurses for conscious awareness o f the cultural, political, and social variables that
have global and individual effects on health was made visible through this study. Social,
cultural, and political aw areness o f w om en’s status, birth, m odels o f care, and nursing
practice w ere essential to the nurses in this study recognizing injustices in w om en’s care.
A sense o f em pathy and aw areness o f w hat “ought to b e ,” em erged from the participants’
internalized values that w ere influenced by their nursing education. This social aw areness
m ade advocacy actions possible.
12. N ursing education should be grounded in scientific principles and im bued with
personal m eanings and grow th experiences. The new graduates in this study validated the
im portance o f know ing the clinical context o f the situation for understanding the options
o f care that w ere appropriate. Scientific know ledge on th e norm alcy o f childbearing and
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new bom care was required for the participants in this study to validate w hen care was
w om an-centered and w hat choices in care could enhance the experience. The nature in
w hich the new graduates in this study reported learning w om an-centered care that
blended their personal lives, schooling, and nursing practices, highlighted the im portance
o f nursing curriculum being a path o f life. The transform ative nature o f this curriculum
was evident through the w ays the nurses’ know ledge o f w om an-centeredness changed
and influenced both their personal lives and nursing practices. The experiences o f
learning w om an-centered care in nursing school provided self-aw areness o f gender issues
that continued to influence the nurses’ s e lf developm ent.
13. A nursing faculty is obligated to teach to transform patriarchal and paternalistic
health care practices to w om en-centered/patient-centered caring practices. This
assum ption was not supported by the findings o f this study. This assum ption cannot be
supported by the findings o f this study, since this b e lie f represents m y personal values.
The study findings, how ever, illuminated the oppressive nature o f health care delivery
and the need for nursing faculty to teach so that future m aternity nurses will be aw are o f
how' the environm ent can be changed to improve m aternity services. The findings o f this
study highlighted the strengths o f feminist pedagogy and w om an-centered ideology to
influence practices and im prove situations o f care. Y et m aternity nursing faculty, as w ell
as nurses in practice, m ust consider that w om an-centered philosophy provides space for
w om en to rem ain in health care situations controlled by patriarchal traditions, when this
is w'hat they prefer.
14. M odem progress in science and technology has the potential to be both beneficial
and harmful to human life. Appropriate use o f science and technology m ust be considered
within the context o f the situation. This assumption w as supported by the findings o f the
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study. The findings indicated w om en and babies were exposed to technology that was life
saving in certain situations. Technology was described as especially useful in high risk
and em ergency care. The availability o f suction and oxygen w as considered safety issues
for normal births. There were other instances, however, w hen the use o f technology w as
centered on controlling or speeding up labor for the convenience o f caregivers. W om en’s
experiences w ere controlled by unnecessary use o f continuous fetal m onitoring which
limited the options for comfort measures. R outine procedures such as forceps and
episiotom ies were described as potentially harm ful and affecting postpartal recovery.
These findings supported my b elief that the use, benefits, and risks o f technology must be
evaluated within the context o f each w om an’s experience.
15. The culture o f m odem W estern health care that is centered upon m edical
intervention and technology is “taken-for-granted” and greatly influences health care
decisions. This assum ption was supported by the findings o f the study. T he nurses in this
study described w orking in settings were routine medical interventions, such as epidurals
and pitocin augm ention, became the “norm” for birth, w hile natural birth w as the
anom aly. Nurses, women, and physicians took these practices for granted. These
dom inant practices left little room for the possibility o f com peting discourses and
alternative ways to give birth. The nurses in this study found it was only w hen the w om en
becam e know ledgeable o f alternatives and w ere empowered before entering the hospital,
were they enabled to give birth w ithout many o f the routine interventions.
16. The litigious culture surrounding the delivery o f healthcare impacts professional
caregiver’s care decisions and ultimately impacts healthcare possibilities. This
assum ption was supported by the findings o f the study. The presence o f legal obligations
were em bedded w ith the power relations concerning nurses’ legal obligation to carry out
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doctors’ orders and follow hospital protocols o f care. T he nurses in this study w ere aw are
o f their legal obligations to provide care within certain standards. They w ere w illing to
confront others o r refuse to participate in care that w as unsafe and m ight result in patient
injury' or legal liability. Likewise, if the order was determ ined consistent w ith unit
protocols the nurses reported being obligated to carry it out. This study does not consider
the physician’s perspective or the w om an’s perspective on how legal liability influences
care decisions.
17. Pow er structures in society influence nursing education and practice. This
assum ption was supported in the findings o f the study. This study exposed the close
relationship betw een medical discourse and nursing discourse. Routine nursing care
practices, as illum inated in this study, conformed to support technology and the choice
for medical intervention during birth. The otherness experienced by nurses in this study
resulted from the pow er o f traditional pedagogies to m arginalize and devalue a fem inist
theory in nursing education and practice. Com peting discourses for m aternity nursing
education and a w om an-centered philosophy o f care w ere controlled and m inim ized by
dom inant pow er structures.
There were two assumptions that I failed to delineate in the research proposal but
I realized w ere prem ises for this study. First, I assum ed w om an-centered care w ould
result in improved m aternity care. This assumption w as based on research literature that
identified risks to routine medical interventions and w o m en ’s needs for m ore nursing care
to focus on interpersonal and psychosocial needs during childbirth. From the nurses’
perspectives, the research findings in this study supported this assum ption. The
participants believed when they acted within a w om an-centered philosophy to change
care situations, the w om an’s m aternity experience w as enhanced and nursing care w as
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im proved. T heir stories o f care supported this b e lie f by describing positive outcom es o f
care and enriching experiences for women. This study, however, did not seek the
w om an’s perspective, w hich would be key to validating this assum ption.
A nother m ajor assum ption that I did not delineate was m y b elief that w om an-
centered m aternity nursing education can contribute to changing m aternity practices
through the know ledge and em powerm ent o f new graduates w ho becom e m aternity
nurses. The potential for changing the individual practices o f m aternity nurses to focus on
w om an-centered care w as supported through this research. The nurses in this stu d y were
able to describe instances when they applied their w om an-centered values o f care to
make, w hat they believed, was a positive difference in the w om an’s experience. Y et the
barriers to w om an-centered care identified by the nurses in this stu d y also illum inated the
m any levels o f social change needed to make w om an-centered care the norm. T he
inherent pow er o f m edical discourse, along w ith w o m en ’s expectations and th eir lack o f
know ledge o f childbirth options, w ere a deterrent to nurses offering women choices. The
professional m aturity required for the new graduates to challenge the system w as
dependent on contextual factors such as their length o f em ploym ent, the support o f
nursing m anagers and colleagues, and the clinical situation. In com plex situations that
involved changing m edical interventions, higher level skills o f professional collaboration,
advocacy, and em powerm ent-building were required by the nurses. The nurses’ education
in w om an-centered m aternity nursing was instrum ental to their personal developm ent o f
a w om an-centered philosophy and beginning practices in w om an-centered care. The
barriers to w om an-centered care that were described by the nurses in this study, how ever,
w ere outside the scope o f influence o f undergraduate nursing education w ithout
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collaboration w ith medical education, nursing and m edical professional organizations,
health care institutions, and w om en.
Theoretical Context o f the Study
Fem inist-Postm odern T heory
The theoretical context o f the study was essential to understanding the study
findings. W hat a woman-centered m aternity nursing curriculum meant to nurses in
practice required interpretation through layers such as gender, power, post-m odem ism ,
w om en-centereness, otherness, liberatory education and nursing praxis. The education
and practice realities revealed through this study further substantiated the theoretical
assertions m ade about gender, the culture o f childbirth, and the potential o f liberatory
education to effect changes and enhance lives.
Postm odern theory w as useful as a critique o f m odernity to understand the
consequences o f twentieth century progress and technology on the human experience o f
childbirth. U nderstanding the postm odern condition m eant recognizing that the birth
process was both enhanced and harm ed by twentieth century values o f progress, control,
efficiency and outcomes. The findings o f this study highlighted the struggle between
natural birth and medically focused birth and revealed the effects m odernity had on
m aking scientific interventions available and difficult for w om en to refuse in W estern
culture.
Foucault’s (1977/1980) postm odern theory o f po w er linked values o f m odernity
to the pow er o f medical discourse that was accepted as a “regim e o f truth” (p. 131). The
dom inant childbirth culture described in this study w as created through the pow er o f
m edical discourse to represent the truth about childbirth. Finding truths through a
com peting discourse o f w om an-centered birth was an experience o f otherness, according
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to the nurses in this study. The nurses in this study faced the pow er o f medical discourse
anytim e they decided to advocate for options outside the medical paradigm. Foucault’s
theory o f power exposed the pow er o f discourse over birth to restrict and define birth
experiences for w om en.
The disciplinary functions o f surveillance, norm alizing judgm ents and
exam ination were evident as the nurses described the barriers to w om an-centered care.
The nurses in this study described the pow er o f surveillance that required constant
fetal/m atem al electronic m onitoring o f women during labor. The need for constant
monitoring, in turn, controlled w om en and restricted care. W om en’s confinem ent to the
bed prevented nurses from offering ambulation and showers as com fort m easures.
N orm alizing judgm ents controlled w om en by establishing standards o f behavior for
typical labor and m atem al/new bom care. Nurses in this study reported tim ing the
frequency and duration o f contractions and checking cervical dilatation so that labor
could be sped up to conform to preset standards o r to control the tim e o f birth for the
physician’s convenience. W om en w ere expected not to yell or get out-of-control during
labor. Epidural anesthesia was offered as a way to control the sounds and m ovem ent o f
wom en during labor. Since the urge to push was usually dim inished, one nurse in the
study confirmed that epidural anesthesia was also used as a w ay for health professionals
to m anipulate the tim e o f birth. In this study, Foucault’s notion o f the power o f
exam ination, was related to the p ow er o f the medical record to exert power ov er women
and nursing practices. The nurse w as required to observe and record data for future use
by other health experts. The nurses’ surveillance and necessary recording o f d ata often
violated the cultural m eanings o f privacy for some women, such as observing
breastfeeding. The nurse was required to observe breastfeeding and to report th e findings.
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The nurses in this study described situations w hen data were interpreted by o th e r staff
using judgm ental attitudes and w ithout considering the social context o f the w om an ’s
life.
Pairing feminism and postm odernism illum inated the diverse m eanings and
circum stances o f gender oppression in society. The pow er o f consciousness raising within
a fem inist-postmodern theory w as illum inated through the research data. T he nurses in
the study knew that considering the individuality o f women and th e context o f their lives
was essential to know ing what w om an-centeredness meant to w om en from diverse social
and cultural backgrounds. There w as no universal meaning in w hich to define the ideal
birth. The awareness o f potentially oppressive practices m otivated the nurses in this study
to m ake a difference through advocacy actions and educational strategies to facilitate
em powerm ent. The fem inist strategies used by the nurses to offer w om en alternatives and
change their experiences supported fem inist (A llen, 1996; D eveaux, 1996) b eliefs that
w om en and nurses can overcom e Foucault’s (1977/1980, p. 138) notion that the
disciplinary functions o f m odem system s produce a “docile body.” The findings o f this
study displayed ways that nurses and w om en liberated them selves in situations to
overcom e the controls imposed on them by dom inant, modem system s. This liberation,
however, was dependent upon contextual factors. T he degree o f resistance w as dependent
on factors such as professional developm ent, cultural support, and know ledge o f the
pow er structures (A llen, 1996).
The nurses’ descriptions o f practicing wom an-centered m aternity n ursing in this
study were consistent w ith the philosophical and operational tenets o f w om an-centem ess
described within the feminist theory o f the w om en’s health m ovem ent (R uzek, 1978).
The nurses in the study w ho em bodied a w om an-centered philosophy view ed childbirth
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as a norm al life transition for women, rather than a pathological crisis. The nursing
actions described in this study to prom ote w om an-centered care challenged the
m edicalization o f norm al birth and sought to affirm the im portance o f birth in relation to
the context o f w om en’s lives (M organ, 1998). The n u rses’ practices revealed the m eaning
o f closeness, honesty, autonom y, personal touch, and use o f time w ithin a w om an-
centered perspective. Likew ise the different m eanings o f these concepts in m edicalized
births w ere highlighted as the nurses faced the barriers to im plem enting a w om an-
centered philosophy.
T he C ulture o f C hildbirth
T he contrast betw een a w om an-centered birth paradigm and a culture o f
technocratic birth, as theorized by D avis-Floyd (1992; 1996) was evident from the
n urses’ descriptions o f birth settings described in the study findings. C onsistent w ith
D avis-F loyd’s research, these study findings also indicated that a m ajority o f w om en
entered the health care system readily trusting in the technocratic system o f care to
facilitate their birth. This w as a point o f frustration for the nurses in this study w ho could
envision better possibilities for women. The pow er o f the technocratic system to protect
the interests o f science and the patriarchy and to socialize women into the dom inant birth
culture w as m ade possible by controlling w om en’s choices and know ledge o f
alternatives. A uthoritative knowledge o f birth rested prim arily w ith the physician (Jordan,
1997). T he nurses in this study verbalized fear and anxiety over giving w om en too m uch
inform ation that conflicted with the physician’s plan. As the nurses in this study
developed professionally, som e learned the art o f involvem ent and advocacy and learned
how to relay inform ation w ithout violating their com m itm ent to the institution o r the
physician.
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M aternity Nursing as Praxis
T he forms o f nursing resistance to patriarchal control o f w om en’s experiences and
know ledge as described in the findings represented a form o f nursing praxis (Ballou &
Bryant, 1997; Henderson, 1997; M ason et al., 1991; M cCorm ick & Roussy, 1997). B eing
consciously aware o f their actions, the nurses in the study acted on their know ledge o f
w om an-centered care and looked for opportunities to im prove w om en’s experiences in
the health care system. They recognized their w om an-centered viewpoint as an
experience in being “other” as com pared to colleagues who did not display sim ilar values
and identified ways they practiced to challenge the status quo to improve w om en’s
experiences.
N urses in this study w ere able to acknow ledge the social and environmental
variables that influenced w om en’s care. They dem onstrated critical consciousness o f how
social history, race, body weight, and sexual preference influenced w om en’s experiences
in childbirth w ithin the health care systems in w hich they w orked. They verbalized
tolerance o f w om en’s differences. The nurses considered the social context o f w om en’s
lives as they provided care. They distanced them selves from judgm ental and disrespectful
attitudes displayed by those they worked with. Rem aining silent about o th er’s attitudes
concerning w om en was problem atic for the nurses in this study. They articulated under
w hat circum stances they spoke up, and found openings to resist routine practices and
change w om en’s experiences and under what circum stances nursing praxis w as limited.
Liberatory Education Theory
The pow er o f a liberatory education to turn critical thought into em pancipatory
action and to open students and future nurses to a plurality o f perspectives w as
illum inated in the findings o f this study (Greene, 1978, 1988; Lather, 1991). The new
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graduates in the study recalled embracing the multiple discourses presented in the
m aternity course. The feminist-postmodern perspectives o f women, w om an-centered
caregivers, and the traditional medical discourses were blended w ithin the discourse o f
w om an-centered maternity nursing practice. Through this educational experience the new
graduates in this study accepted the truths o f a postmodern, fem inist perspective on
childbirth and internalized the values. G reene (1990) theorized that teaching for critical
aw areness was a way to teach for ethical concern and m ove students to be sensitive to the
context o f lives in a pluralist society. The values and practices the new graduates
articulated w ithin their developm ent o f a w om an-centered philosophy illum inated such an
aw areness o f m ultiple perspectives and em pathy for others. C onsistent w ith G reene’s idea
o f a critical education, the nurses in this study articulated a tone o f concern fo r the
w om en and w ere keenly aware when w om en’s rights were being violated. T h ey struggled
w ith conflicts in ethical obligations to wom en in their care. The sought to advocate for
w om en, provide sensitive care and to educate, and facilitate em pow erm ent o f w om en
w hen possible. The nurses w ere also opened to imagine other possibilities fo r wom en,
rather than only the medical m odel o f care.
The findings indicated the nurses in this study engaged in critical self-reflection
and took on a different vantage point or landscape about w om en and childbirth (Greene,
1978). They m ade a personal connection w ith the course that set them on a course o f life
w ithin this new perspective (Pinar, 1994). T heir schooling, nursing practice, and personal
know ing blended as the participants practiced woman-centered nursing and applied their
know ledge o f woman-centered maternity nursing to their ow n birth experiences, o r
experiences o f close friends and relatives.
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The new graduates’ experiences dem onstrated the pow er o f liberatory education
to change nurses’ ways o f being in the world o f practice. Yet the findings o f this study
indicated that not all students in the liberatory classroom em braced the critical fem inist
pedagogy and com peting discourse o f w om en-centered health care. The new graduates in
the study recalled the experiences o f peers’ resistance to liberatory pedagogy. Instead o f
perceiving the course as a space to leam different perspectives, the findings indicated
som e students perceived critical ideology as being im posed on them . As Lather (1991)
explained, the goal o f feminist educators is to offer m ultiple perspectives on dom inant
and com peting discourses, while creating space for conflicting view s. Lather’s call for
m ultiple discourses that would open students to understand the pow er o f dom inant
discourse seem ed to support many o f the teaching strategies the participants in this study
reported helpful to them. Reading stories o f other nurses and w o m en ’s experiences in
w om an-centered birth w as balanced w ith learning the routine m edical interventions in the
nursing textbook. W hy some nursing students w ere open to the m ultiple discourses, w hile
others clearly resisted them is unknown and requires further study by nursing educators.
Personal Experiences w ith the Study
I have been a nurse educator for twenty years but this w as m y first opportunity to
have an in-depth conservation with new graduates about their experiences in nursing
education and practice. The opportunity to leam from them through this study w as an
insightful experience. I felt privileged to have contributed any sm all part to the education
o f such a bright, articulate group o f practicing nurses. As they shared their stories I felt
the passion they had for the everyday w ork o f being a nurse. They articulated a deep
concern about the w om en, babies, and families in th eir care. I felt com passion for the
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struggles I heard them facing everyday as they strove to enact their values and beliefs in
providing nursing care.
This study enabled me to view the new graduates as individuals concerned w ith
being good nurses while also negotiating life’s concerns. B eing invited into the hom es o f
m any participants sensitized m e to their o th er lives, as m others, fathers, w ives, husbands,
or being a single adult, w orking woman. I had occasions to meet their fam ilies, w hich
included new borns, toddlers, spouses, m others, cats and dogs. I entered their hom es in
new subdivisions or rem odeled older hom es in rural and suburban areas and apartm ents
in the center o f urban life. I talked on the p hone with them as they w ere also preparing a
meal or conversing w ith children. One participant rescheduled an interview because o f a
sick baby and one rescheduled because she felt “traum atized” due to h er last tw elve hour
shift and felt she would not think about anything else in m aternity nursing but this one
case. This perspective gave me a much greater appreciation o f their struggles in m aking
the transition to professional nursing while also m aintaining personal and fam ily w ell
being.
This study allow ed me to view nursing education and new graduate transition to
practice through the perception o f the student and new graduate who learned w om an-
centered m aternity care. The qualitative m ethodology allow ed me to enter the w orld o f
the new graduates and understand their nursing practices. Engagem ent in the
phenom enologic research process was an experience o f stepping outside the taken-for-
granted know ledge and being open to see the participants’ perspectives from another
view point. D uring the research interviews I listened as the new graduates shared their
experiences in w om an-centered maternity nursing education and practice. I listened for
the tensions o f professional development and barriers to w om an-centered m aternity
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nursing. As I conducted the interviews and analyzed the texts, I pondered the ways
undergraduate education might better prepare them for the com plexities o f practice.
W hen the nurses in the study talked about the problem s o f practicing w om an-centered
care, I felt responsibility to understand their struggles in practice. I was constantly
considering w hat other skills concerning collaborative practice and advocacy that nursing
education needed to teach to assist the new graduates to attain w om en-centered care in
the highly m edicalized settings.
This study gave m e a sense o f awe concerning the p o w er o f educational
pedagogies. I was som ew hat surprised that the participants displayed the ability to
articulate their nursing care w ithin a woman-centered fram ew ork where nursing advocacy
and em pow erm ent w ere common struggles. I taught w om an-centered care to nursing
students in the hope o f their becoming conscious o f w om en’s experiences and embracing
a w om an-centered philosophy o f maternity care. Even though I taught for this awareness,
I w as still surprised at the ease in which the participants analyzed their practices around
fem inist concepts o f power, control, and choices, especially since most o f the new
graduates had only been out o f school between one and tw o years. The n ew graduates and
I shared com m on m eanings about woman-centered care. W e had a com m on language to
talk about w om en’s experiences and childbirth practices.
This study reaffirm ed my beliefs about the pow er o f narrative pedagogy because
reading the birth stories was the teaching strategy the new graduates in the study
rem em bered about the maternity course. The study reaffirm ed m y beliefs that m ost new
graduates learned nursing skills specific to the clinical setting in a short period o f time.
As shown in this study, the most difficult aspect o f nursing th at the new graduates
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struggled with involved learning to recognize needs and connect with people to make a
difference in their care, and to negotiate the health care system .
I rem ain com m itted to learning the ways fem inist-postm odern pedagogy can
liberate nursing education to transform lives and em pow er nurses to choose a path o f
concern and advocacy for w om en’s experiences in health care. As I continue to educate
nurses on the possibilities o f woman-centered care, I accept the responsibility to support
their efforts on m any levels. I anticipate supporting nurses’ struggles for w om an-centered
care in practice through further research and education o f nurses, w om en as consumers,
and the health care delivery system.
R ecom m endations for Nursing Education. Practice, and R esearch
In this section, I discuss recom mendations for nursing education, practice, and
research, as I perceive them through my interpretation o f the findings. T he
recom m endations indicate areas for further knowledge developm ent or changes in
education and practice related to feminist-postmodern pedagogy and w om an-centered
m aternity nursing. N ursing educators, nursing service adm inistrators, m aternity care
m anagers, clinical preceptors, and nurses in practice can evaluate the stu d y findings and
the recom m endations to direct future knowledge developm ent o r make changes in
education and practice.
N ursing Education
I recom m end th at maternity nursing education be based upon a philosophy o f
w om an-centered care im bued by feminist-postmodern pedagogy. The nurses in this study
described the transform ative nature o f the m aternity nursing course that provided an
opening for them to em brace a woman-centered philosophy and begin to integrate it into
the reality o f practice, a s a basis for involvement and advocacy. M aternity nursing
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curricula need to be designed using feminist pedagogy that supports the principles o f
w om an-centered care. This study illuminated the pow er o f fem inist pedagogy to connect
nurses to w om en’s concerns and experience their education through critical aw areness o f
dom inant childbirth discourses. As dem onstrated by the nurses in this study, fem inist-
postm odern theory in nursing education has the potential to liberate nurses to recognize
oppressive health care practices and stimulate nursing praxis that changes w o m en ’s
experiences (G reene, 1978; 1988). Nurses educated in w om an-centered care have
know ledge o f m ultiple care alternatives and value w om en’s autonom y in m aking choices.
A w om an-centered philosophy needs to be included w ithin core m aternity curricula so
that nurses have the opportunity to value this perspective and can contribute to
transform ing m aternity services for women. This study also illum inated the pow er o f this
pedagogy to transform the nurses’ personal lives and birth experiences (Pinar, 1994). The
nurses’ aw akened engagement w ith w om an-centered ideology transform ed th eir
perspectives about w om en, childbirth, and nursing, and enriched their personal birth
experiences.
I recom m end nursing faculty with lim ited knowledge o f w om an-centered care and
fem inist-postm odern pedagogy seek m entoring and education that w ill open them to the
possibilities o f this philosophy and teaching m ethodology to contribute to the
transform ation o f m aternity nursing care. N ursing conferences in nursing education and
w om en’s reproductive care need to offer sessions that focus on fem inist theory to educate
faculty. N ursing faculty who have experience applying feminist theory to w o m en ’s health
and nursing education need to continue to educate others through w riting about their
experiences in nursing publications and presenting at conferences.
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I recom m end professional education that offers opportunity to teach collaboration
betw een nurses and other care providers, such as physicians. The findings o f this study
indicate that health care professionals need to leam the art o f collaboration directed
tow ard a woman o r patient-centered philosophy o f care. C ollaborative nursing and
m edical education w ould prepare these practitioners to w ork together in practice to
provide maternity care w ithin a w om an-centered model.
N ursing Practice
I recom m end that m aternity nursing services em brace a philosophy o f w om an-
centered care in practice. The findings o f this study exposed the caring aspects o f this
philosophy as a fram ew ork from w hich to provide gender sensitive care and prom ote
nursing advocacy and em pow erm ent-building strategies to im prove m aternity services.
The context o f the w om an’s life and the personal meanings o f her experience were
prim ary concerns for the nurses in the study.
I recom m end that nurse m anagers and nurses in practice w ho w ere not educated
in w om an-centered care in their basic nursing education becom e exposed to the m eanings
and possibilities for im proving care for women through a w om an-centered philosophy.
Inservices, continuing education courses and graduate nursing courses need to be
available to educate nurses to m ultiple perspectives in m aternity care and potentially
sensitize them to w om en’s need for choices and autonom y.
I recom m end that m aternity nursing services work to expose and minim ize
barriers to w om an-centered care that are embedded in the health care delivery system .
H ospital-based prenatal education needs to refocus on educating w om en on m ultiple
alternatives and m aking informed choices. Routine protocols and orders for labor
adm ission should be reevaluated for the necessity o f these interventions for all w om en.
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based on evidence-based research. N urses in practice need reeducation in principles o f
w om an-centered alternatives, including comfort care during unm edicated births.
Dialogue and collaboration with physicians about care issues need to be im proved and
refocused on the w om an’s concerns and needs. The frequency and m eanings o f labor
induction for women need to be discussed among w om en, nurses, and physicians so that
w om en’s best interests are served.
I recom m end that new graduate orientation and preceptorships in practice focus
on the developm ent o f w om an-centered skills o f involvement, patient education, g rie f
counseling, and advocacy, along w ith developm ent o f clinical know ledge. A ssertiveness,
leadership, and collaboration skills require continued developm ent in practice to prom ote
the developm ent o f w om an-centered advocacy. Nurturing support o f new graduates by
nurse m anagers and peers is indicated, especially in high volume, stressful environm ents.
Support groups or special educational sessions about transition to practice issues is
needed throughout the first three years o f practice to support new graduates as they
assimilate their values into practice and leam how to negotiate the system .
I recom m end the education and employment o f m ore advanced practice nurses in
the m aternity settings, including the nurse practitioner, the clinical nurse specialist, and
the nurse midwife. The nurses in this study, as well as their clients, w ere rarely exposed
to these caregivers in the settings. These graduate-educated nurses often have m ore
exposure to alternative possibilities for w om en and can act as role m odels for new
graduates for learning patient involvem ent. This study revealed that the lack o f m idw ives
limited w om en’s birth options and the opportunity for w om an-centered nursing practices.
If available, the m idw ifery model o f childbirth and w om an-centered nursing practices
could com plim ent each other w hile centering on the w om an’s birth goals.
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I recommend m ore efforts be made to educate all women about childbirth issues
and safe alternatives for birth. Changes in the philosophy and purpose o f prenatal
education needs to be assessed through the viewpoints o f consumers, childbirth
educators, nurses, and birth attendants. W om en and nursing organizations, w om en’s
studies departments, and nursing schools at university settings need to address these
issues in com m unity service projects and public service advertising. N urses in practice
and education need to share their know ledge o f childbirth alternatives w ith w om en
w henever the opportunity arises. M aternity nurses need to w rite articles about childbirth
choices and w om an-centered care in m agazines, newspapers, and new sletters intended to
educate w om en and men.
Nursing Research
I recommend further exam ination o f the possibilities and lim itations o f using
feminist-postm odern pedagogy in nursing education. M aternity nursing educators need to
evaluate the findings o f this study to determ ine if wom an-centered ideology w ould b e a
useful framework for teaching m aternity nursing practice. In this study, the nurses had
retained their knowledge and values o f w om an-centered philosophy from betw een six
m onths to three years. T his study could be continued to investigate w hether the nurses
retained fem inist values over a longer period. As the nurses in this study continue th eir
professional developm ent, how will their wom an-centered perspectives, values, and
actions change?
I recommend further study be done w ith nurses w ho, over a longer period o f tim e,
attempt to negotiate barriers to w om an-centered care. Nurses in the study reported
feelings o f frustration dealing with tensions associated w ith negotiating barriers to
w om an-centered practice. Do these frustrations and barriers contribute to “ bum out” over
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tim e as other nurses in practice have articulated (D iam ond, 1996) o r does their
involvem ent w ith and contribution to w o m en ’s care sustain them ? Studying nurses over a
longer span o f tim e w ould describe under w hat conditions the nurses’ skills in being
w om an-centered im prove o r deteriorate. T he conditions o f practice that support further
developm ent o f w om an-centered skills o f involvem ent and advocacy could be described.
I recom m end that the experiences o f new graduates w orking in areas outside
m aternity nursing, w ho were educated w ithin feminist pedagogy and a w om an-centered
philosophy o f care, be researched. This w ould allow fo r further evaluation o f the
em pancipatory potential o f this pedagogy to affect n u rses’ practices in other settings. The
follow ing question m ight be posed. Do nurses who accepted a w om an-centered
philosophy o f care sustain and transfer th eir values to a patient-centered philosophy in
diverse clinical situations? H ow are their personal lives and birth experiences influenced?
I recom m end that nursing educators study the barriers to m ainstream ing liberatory
pedagogies w ithin nursing curricula. T he new graduates’ m em ories o f learning w om an-
centered care in their m aternity course included experiences in being other. The new
graduates in the study recognized the atm osphere and theoretical tenets in this course
w ere m uch different than in other courses. A sense o f otherness that em erged from these
new graduates’ educational experiences illum inated the universality o f behaviorist
pedagogy in nursing curricular. Research questions w hich m ight be posed in future
studies include the following. W hy are pedagogies that elicit personal connections and
nursing praxis and strengthen ethical and critical know ledge still m arginalized by nursing
faculty and students? W hat are the forces that sustain traditional, patriarchal teaching
m ethodologies in nursing curricula?
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I recom m end that the student resisters to feminist pedagogy be studied to explore
w hy certain students grasp the significance o f wom an-centeredness in practice and
education and some do not. The new graduates in this study recalled student peers in the
course w ho clearly rejected fem inist theory, w om an-centered ideology and/or the
fem inist structure o f the classroom. Q uestions that might be posed include: A re there
personal characteristics or historical aspects o f the learner that affects their openness to
m ultiple discourses? How does th eir previous educational experiences influence student
acceptance or resistance? How m ight educators teach liberatory perspectives as an
opening rather than an imposition?
I recom m end maternity nursing service adm inistrators and managers evaluate the
findings o f this research to better understand w ays the culture o f practice and the barriers
to w om an-centered care influence nurses’ practices and w om en’s experiences. The
m eaning o f woman-centered care to im proving maternity outcom es and w o m en ’s
experiences requires further study. W om en’s perspectives require consideration.
Phenom enological study to describe w om en’s perspectives about their care is indicated.
Likew ise, there needs to be further research on the impact o f routine medical and nursing
interventions on the outcomes o f care. Future research needs to describe w o m en ’s
feelings and m eanings associated w ith the experience o f childbirth, as well as the
physiologically-based outcomes.
I recom m end that different models o f care and the philosophical base o f nursing
care in m aternity settings be further studied. T here is a need to further validate and
describe any possible differences in care betw een nurses w ho practice within a w om en-
centered philosophy and those w'ho do not. O ther viable fram eworks for delivering
w om an-centered care require identification and study. O utcom es for m aternity m odels o f
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care such as m other/baby nursing, doula and m onitrice care in labor, midwifery staffed
birthing centers, and prim ary nursing care, require continued evaluation. Em powerm ent
models for prenatal education need to be explored. Hospitals or birthing centers that are
striving to implement the “M other-Friendly C hildbirth Initiative” (Coalition for
Im proving M aternity Services, 1996) should be studied to evaluate the strategies used.
I recommend nursing research that explores w ays to expose and alter the pow er
im balance am ong women/clients, nurses, and physicians. Nursing and medical education
needs to continue to im prove ways to educate for m ore collaborative models o f w ork
relationships that center on the w om an/client. Further research is required to describe the
strengths and limitations to collaborative models o f practice.
Ethical dilem m as in maternity practice that result from the w ay care is delivered
in the health care system needs to be illum inated and further explored. This study
exposed areas that require further analysis. The use o f obstetrical tim e management,
staffing issues, and the nature o f hospital-based prenatal education w ere among the
ethical dilem m as exposed through this research study that remain ripe for further study.
The w ay nurses deal w ith ethical issues o r conflicts in practice values needs exposing.
N ursing service departments need to evaluate the channels opened to nurses to take their
concerns forward when ethical issues affect patient care. The risks to nurses who report
issues needs to be m inim ized and effective strategies planned to address the issues.
I recommend nurse educators and nursing service managers continue to study
ways to prepare nurses for the realities o f practice and to support them through the
transition to professional nursing practice. Nursing education preceptorships, new
graduate orientation, and continued professional developm ent o f nurses require further
study. Supportive environments that prom ote professional developm ent need further
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explication. W ays o f supporting the new graduate through especially difficult tensions,
such as em ergency situations and patient death need to be m ore fully explicated.
I recom m end the processes o f teaching and prom oting nursing advocacy be more
fully researched. The conditions for advocacy and the reasons w hy some nurses choose to
advocate on behalf o f others need m ore clarification. There is a need to understand what
role nursing education and critical pedagogies that teach social responsibility have on
nursing advocacy behaviors. The differences that occur in outcom es o f care and patient
satisfaction following acts o f advocacy need further explication.
Summ ary
In this chapter I discussed conclusions based on m y interpretation o f the findings.
M y assum ptions for the study were review ed and analyzed w ithin the study findings.
Likew ise, the theoretical context o f the study was related to the findings. M y personal
experiences w ith the study w ere described and recom m endations for nursing education,
practice, and research w ere formulated.
Conclusion
T he purpose o f this study was to describe the m eanings o f the clinical experiences
o f registered nurses w orking in m aternity settings subsequent to studying m aternity
nursing from a feminist perspective in nursing school. The m eanings were explicated
through the stories o f m aternity nurses regarding their m em ories o f nursing education and
their experiences as new graduates in practice. I interpreted the stories o f m aternity
nurses, based on the philosophical work o f Heidegger, and through the lenses o f feminist-
postm odern theories.
T he w ays a w om an-centered m aternity nursing course im bued with fem inist-
postm odern theories, can transform ed nurses’ perspectives about w om en and
346
childbearing and serve as a catalyst for w om an-centered practices was illum inated. The
pow er o f liberatory pedagogy to elicit critical consciousness, personal m eaning, m ultiples
perspectives and student connection and resistance, w ere m ade visible in this study. T he
w om an-centered maternity nursing course opened the nurses in this study to critique
practices and consider the personal meaning o f birth and new born care in the lives o f
w om en. The nurses were aw are o f multiple possibilities for birth. They connected w ith
w om en and som etim es found w ays to im prove care for w om en in m edically-focused and
natural birth situations.
The com plexities o f gender, childbearing, and w om an-centered m aternity nursing,
rem ain evident from the nurses’ experiences and require further study. T he m ultiple
forms o f pow er in the dom inant birth culture continued to control and define the w ork o f
nursing and the choices o f w om en and represented barriers to w om an-centered care. The
nurses in this study, however, offered hope that through w om an-centered education and
praxis there were openings to create w om an-centered care and support com peting
discourses in m aternity care. T he fem inist-postm odern perspective o f B oth/A nd set up the
possibility for aspects o f woman-centered care to perm eate w om en’s care as a com peting
discourse to decenter the dom inant medical discourse. T he Both/A nd perspective w ithin
the discourse o f w om an-centered maternity nursing respected the possibilities o f nature
and science to coexist while giving women choices and hum anistic experiences in
m aternity care.
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APPENDIX A
Letter to Participants
Dear Colleague:
I am a student in the doctoral program at G eorgia State U niversity’s School o f N ursing. I

am currently conducting a study about new ly graduated nurses’ experiences in m aternity
practice. The purpose o f this study is to uncover the m eanings o f clinical practice to new
registered nurses w orking in m aternity settings after studying m aternity nursing from a
feminist, w om an-centered perspective in a baccalaureate nursing program .
I am seeking to conduct a personal interview w ith each nurse who agrees to participate in
the study and meets the criteria. The interview would be conducted at a place and tim e
convenient for you, or b y telephone, if necessary. Interviews will focus upon nurses’
descriptions o f their everyday practices as maternity nurses, the values that guide their
practice, and the enabling and/or constraining factors to providing m aternity nursing care.
As you reflect upon your academic experiences learning m aternity nursing and your
experiences w orking as a registered nurse in maternity settings, please think about the
following before the interview:
“ W hat are your m em ories o f learning w om an-centered m aternity care in

nursing school?” “ W hat does learning a w oman-centered philosophy o f
care m ean to your current practice?” “Describe particular clinical
situations that stand out for you in your clinical practice.” “W hat beliefs
about m aternity care influenced your role in these clinical situations?”
W hat does being a m aternity nurse m ean to you in your personal life?
If you agree to participate, we will set up the interview and perhaps a follow-up interview
at a later tim e to discuss findings.
I f you have any questions at any time, please call me at hom e (504) 467-2674 or at m y
office (504) 5 6 8 -4 1 6 7 .1 appreciate your interest in participating in this research project.
If you know o f any other peers from nursing school who are practicing as m aternity
nurses, please let me know or share this letter w ith them.
Sincerely,
Gloria Giarratano, RNC M SN
384
APPENDIX B
C onsent Form
I have been invited to participate in a research study designed to explore the m eaning o f
m aternity nursing practice after being educated in a w om an-centered (fem inist)
philosophy in m y undergraduate m aternity nursing course. Participation is com pletely
voluntary.
W hat does the studv consist of?

The study consists o f one audiotaped interview , lasting approxim ately 60 m inutes. The
interview m ay be shorter o r longer if I desire. I w ill be asked to recall m em ories o f m y
academ ic study o f m aternity nursing in the undergraduate nursing course and to recall
stories o f m y clinical practice experiences in m aternity nursing since w orking as a
registered nurse. I will also be asked to discuss the im pact o f m y professional experiences
on m y personal life. I m ay be asked to m eet for another personal or phone interview after
the initial transcription o r analysis o f the interview to clarify points in the transcript. I f I
prefer not to be contacted for another interview I can indicate that by initialing here.
Are there anv risks?

Through recalling and discussing my story, anticipated risks include transient feelings
related to the recollection o f painful m em ories or thoughts. Long lasting effects are not
expected. In the unlikely event that I becom e anxious o r upset from discussing such
experience, I will be referred to a local m ental health source that I can contact for
counseling or support.
Are their anv benefits?

I m ay experience a sense o f satisfaction o r w ell-being by sharing my perspectives o f m y
academic education and m y professional experiences in and adjustm ents to the realities o f
practice. I will contribute to nursing research concerning the educational needs and
support system s required for new graduates entering m aternity practice and contribute to
the know ledge needed to im prove nursing services for childbearing w om en in the health
care delivery system.
W hen and w here will the interview take place?

The interview will be scheduled at a tim e and place convenient for me. Interviews m ay
also be done by telephone, i f necessary, o r if I prefer.
How w ill vour confidentiality be protected?

My decision to participate in this study and all inform ation shared will rem ain
confidential. The interviews w ill be conducted in a private setting. The audiotaped
interviews will be transcribed by a confidential secretary. A udiotapes will be kept in a
385
386
locked file in the researcher’s office and destroyed at the com pletion o f the study.
Identifying inform ation w ill be rem oved o r altered on the transcript, so that all transcripts
seen by anyone other than the researcher w ill be anonym ous and identified only by a
num ber o r fictitious nam e. Transcripts w ill be shared w ith a G eorgia State U niversity
faculty advisor and w ith tw o additional nurse researchers who are m em bers o f the
researcher’s team.
W hat if you change v o u r m ind?

I am free to w ithdraw from this study o r rescind m y perm ission for the use o f m y
transcript at any time.
W hat if vou w ish m ore inform ation?

I m ay ask questions about this project o f the researcher, Gloria G iarratano, or h e r advisor,
Dr. Tom m ie Nelms at G eorgia State U niversity.
Before I sign this form, I w as given an opportunity to ask any questions I had regarding
any aspects o f the study that were unclear.
AUTHO RIZA TIO N: I have read and understand this consent form and I agree to
participate in this research study. I understand that inform ation I provide will not b e used
in any w ay that personally identifies m e. M y signature indicates m y perm ission for the
inform ation I provide in th e audiotaped interview and transcription o f the sam e to b e used
for publication in research articles, books/or sym posia o r nursing research m eetings. M y
signature also indicates th at I have b een given a copy o f this consent form.
Signature:
Date:
Telephone N um ber:
If you need additional inform ation, please contact:
G loria Giarratano or Dr. T om m ie N elm s

1301 Vintage Drive A ssistant Professor
Kenner, LA 70065 G eorgia State U niversity
504-568-4167 (Office) School o f Nursing
504-467-2674 (Home) PO B ox 4019
A tlanta, G A 30302-4019
404-651-3165 (O ffice)
or
Georgia State U niversity

Institutional Review B oard (IRB)
404-651-1350

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INFORMATION TO USERS

The quality of th is reproduction is dependent upon th e quality of th e

Oversize materials (e.g., maps, drawings, charts) are reproduced by

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Bell & Howell Information and Learning

This dissertation, WOMAN-CENTERED MATERNITY NURSING

Tommie Nelms, R.N., Ph.D.

Linda McGehee, R.N., Ph.D.

Dorothy HueneClce, Ph.D.

William Doll, Jr., Ph.D.

Ju d ith L. Wold, R.N., Ph. D.

Sherr^ Gaines, R.N., Ph.D.

In presenting this dissertation as a partial fulfillment o f the requirements for an

G loria Peel Giarratano

The author o f this dissertation is:

Gloria Peel Giarratano

The director o f this dissertation is:

Dr. Tommie Nelms

NAME OF USER ADDRESS DATE TY PE OF USE

Gloria Peel Giarratano

ADDRESS: 1301 Vintage D rive

1984-Present Assistant Professor o f Clinical Nursing

PROFESSIONAL SOCIETIES AND MEMBERSHIPS:

WOMAN-CENTERED MATERNITY NURSING EDUCATION AND THE

LIVED EXPERIENCE OF NEW GRADUATES IN MATERNITY PRACTICE

o f registered nurses working in maternity settings subsequent to studying maternity

nursing from a feminist perspective in a generic baccalaureate nursing program. The

interviews focused on the nurses’ descriptions o f their everyday practices as maternity

to providing woman-centered maternity nursing care. A hermeneutical analysis process

developed by Diekelmann and Allen (1989) and a feminist-postmodern perspective were

Otherness, Being and Becoming Woman-Centered, and Tensions to Practicing Woman-

woman-centered care through nursing involvement, advocacy and empowerment-

tensions, barriers and facilitators for providing women-centered care in medically-

focused maternity settings. Nursing education and nursing practice recommendations

were made to increase and enhance woman-centered care.

LIVED EXPERIENCE OF NEW GRADUATES IN MATERNITY PRACTICE

GLORIA PEEL GIARRATANO

Presented in Partial Fulfillment o f Requirements for

All rights reserved.

Bell & Howell Information and Learning Company

with passion and tenacity.

for research, teaching, and living the life o f a scholar.

I wish to thank the nineteen m atemal-newbom nurses who participated in this

centered practices possible.

Background o f the S tudy............................................................................................... 5

Background o f the Researcher.....................................................................................11

Assumptions Related to the Phenomena o f Concern.............................................. 42

Selected Method and Justification for its Potential................................................. 44

Significance o f the Study to N ursing.........................................................................47

II. Context o f the Study.................................................................................................... 51

Introduction: Feminism and Postm odernism .................................53

Contemporary Fem inism s....................................................55

Liberal Fem inism .....................................................58

Cultural Fem inism ...................................................59

Psychoanalytic Fem inism ...................................... 61

Radical F em inism ....................................................61

Power Relations in the Postmodern:

The Awkward Pairing: Feminism and Postm odernism ............... 68

The Possibilities o f a Feminist-Postmodern

Critics o f a Feminist-Postmodern Constellation.............. 71

Feminist Interpretations o f Foucault’s Postmodern

Feminist/Postmodern Critique as Resistance to

The Feminist Health Movement: A Call for