“Sometimes you miss all
good practices”
An ethnographic study of Respectful Maternity
Care in Malawian Labour Wards
Marleen van den Broek
11249196
University of Amsterdam
Master Thesis Medical Anthropology and Sociology
30 June 2017 - Amsterdam
Supervised by: Dr. Bregje de Kok
Second reader: Dr. Danny de Vries
2 ACKNOWLEDGEMENTS
I would like to thank the Edinburgh Napier University, Robert Gordon University and the University of Aberdeen for involving me in their research project. They gave me the opportunity to choose my own focus while enabling me to use their ethical consent. They brought me into contact with AMAMI, the Association of Malawian Midwives. The staff members and especially the leader of AMAMI, doctor Phoya, were willing to introduce me in the field and helped me to get started. I am grateful for this assistance, since starting a research may be troublesome. I would also like to thank my supervisor, Bregje de Kok, who gave useful advice during my fieldwork and encouraged me with constructive feedback during the writing process. Most of all, I am thankful to the participants in the field who remain anonymous in this thesis. Even though my research did not focus on mothers or guardians, their willingness to participate in the research is of great value. I highly appreciate the opportunity the mothers and guardians gave me, to observe in such an intimate moment in their lives. The 39 deliveries I attended, were special and memorable to me. And finally, I owe a great gratitude to all healthcare professionals, in particular, the nurse-midwives. These nurse-midwives enabled me to follow their day-to-day activities and shared all kind of stories with me. I cannot express in words how much I have learned from them. Without the openness of patients, guardians and midwives, this thesis would not have been the same. Thank you.
Marleen van den Broek
3 Table of Contents ACKNOWLEDGEMENTS ... 2 List of Abbreviations ... 4 Abstract ... 5 1. Introduction ... 6 Malawian context ... 9
A human rights-based approach ... 11
Literature review on RMC: critique and inspiration ... 12
2. Methodology ... 14
Getting access ... 14
Study Location ... 14
Methods ... 18
Data collection and analysis ... 20
Limitations ... 21
Positionality ... 22
Ethical considerations ... 22
3. Care in Context and Culture ... 25
Ethics of Care ... 25
Care as Practice ... 27
Relationships with cooperative and uncooperative patients ... 29
The power game with guardians ... 32
Continuum of respectful and disrespectful care ... 34
Conclusion ... 39
4. Emotions in the labour ward ... 41
Emotional Labour ... 41
‘Feeling rules’ in the labour ward... 43
Midwives: Angels or villains? ... 46
Conflicting perspectives in the labour ward ... 48
Shortage of material resources ... 49
Shortage of human resources... 50
Justifying poor care? ... 52
Conclusion ... 53
5. Discussion & Conclusions ... 55
Limitations ... 57
Trustworthiness ... 58
Conclusion ... 60
Bibliography ... 62
Appendix A – Information Participants ... 67
Appendix B – Topic Guide Interview Midwife ... 68
4 List of Abbreviations
AMAMI Association of Malawian Midwives ANC Antenatal Care
CHAM Christian Health Association of Malawi D&A Disrespectful and Abusive care
DNO District Nurse Officer
HRBA Human Rights-Based Approach MoH Ministry of Health
NGO Non-Governmental Organisation PNC Postnatal Care
RMC Respectful Maternity Care
Cover pictures made by: Marleen van den Broek
5 Abstract
In recent years, there has been increasing interest in Respectful Maternity Care (RMC) in high-, low-, and middle-income countries. This has often been researched while using a human rights-based approach (HRBA). This has failed to consider the local meanings of good quality care. My aim for this thesis is to investigate and identify midwives’ perceptions of Respectful Maternity Care in Malawi to enlarge the understanding of facilitating and hindering factors in providing RMC. The data in this thesis are drawn from extended participant observations and semi-structured interviews with midwives in two heath facilities in Lilongwe District. Two broad theories have guided me in this new focus: ethics of care, for which I was particularly inspired by Tronto (1993), Held (2006), Mol (2010), and Pols (2014), and Hochschild’s (1983) well-known theory of emotional labour. These theories enabled highlighting the context of care practices, the importance of relationships and the central role emotions play in providing care. My study highlights that there is not one mutually exclusive explanation for disrespectful care. Use of fore mentioned lenses illuminates what appears a downward spiral, in which midwives’ humanistic care practices erode due to the interplay of a disabling work environment, the lack of social bonding in the care relationships and midwives’ strong negative emotions.
Keywords: Respectful Maternity Care, midwives’ perceptions, ethics of care, care as practice, emotional labour.
6 1. Introduction
The maternal mortality ratio in Malawi is one of the highest in the world; 634 maternal deaths per 100.000 births, (see table 1, WorldBank 2015a). One of the strategies to reduce maternal and neonatal mortality in Malawi is encouraging women to deliver in health facilities (Kumbani et al. 2012 , 2 ). Studies find that the quality of care can influence women’s choice to visit the health facilities for antenatal or postnatal care and their delivery (e.g. Bowser & Hill 2010, 49; Brighton et al 2013, 225). This underlines the importance of studying quality of care provided by midwives, especially in a setting where the extreme lack of resources places a constraint on this quality (Lugina et al 2002,19).
Studies show that care provided by midwives during childbirth, is not always ‘respectful’ (e.g. Bradley et al., 2016; Kumbani et al., 2012). Okafor and colleagues (2015, 111) for example, found that in Nigeria 98% of the participating mothers experienced disrespectful care during facility-based deliveries. In the last three decades, there has been increased interest in Respectful Maternity Care (RMC). Researchers’ and organisations’ concerns about disrespectful care increased in part because it is seen as a human rights violation (Windau-Melmer 2013, 2 ). The White Ribbon Alliance and its partners therefore articulated seven rights, incorporated in a Charter called: The Universal Rights of
Childbearing Women (White Ribbon Alliance 2011). These rights were preceded by seven
categories of disrespectful and abusive care (D&A) developed in 2010 by Bowser and Hill, who conducted a literature review to synthesise evidence of disrespectful and abusive care (See table 2).
7 The current trend in research about RMC is focussing on these rights of childbearing women and improving the quality of care. Edinburgh Napier University, the University of Aberdeen, Robert Gordon University, and the Association of Malawian Midwives (AMAMI) try together to improve RMC in Malawi by training midwives to make them aware of these rights, and by enhancing the understanding of women’s and midwives’ experiences during childbirth. I contributed to this project by investigating midwives’ view on their work and care they provide, because “it is very unlikely that health workers set out to treat patients badly. Thus, there must be reasons why the end result of the provider–client relationship often turns out to be negative” (Fonn & Xaba 2001 in Bowser and Hill 2010, 23).
These Scottish universities started this project in Malawi, where these disrespectful practices have been detected, as well as in other low-and middle-income countries. Although many studies focused on the quality of care, it has been conceptualised in many ways. It is useful to elaborate on these conceptualisations in Malawi.
The Ministry of Health in Malawi has defined good quality of care as: “doing the right thing, right, the first time and doing it better the next time within the resource constraints and to the satisfaction of the community” (2001, 1 ). But the normative aspect of the definition remains unclear: what is ‘right’?
In addition, the community’s perspective is incorporated but the care provider’s is missing. According to Malawi’s National Reproductive Health Service Delivery Guidelines, Malawi focusses on the receiver’s and provider’s satisfaction when assessing the quality of care (Kumbani et al. 2012, 2). Therefore, they chose another definition, in which quality of care:
“involves providing a minimum level of care to all pregnant women and their new-born babies and a higher level of care to those who need it. This should be done while obtaining the best possible medical outcome, and while providing care that satisfies women and their families and their care providers” (Pittrof et al. 2002, 278 in Kumbani et al. 2012, 2).
This definition seems broader than the definition of the MoH, but it underlines more the medical care than the interpersonal, humanistic care, which is necessary to approach RMC.
Freedman and colleagues (2014) have tried to conceptualise RMC, but highlight the difficulties of defining RMC. They argue that the definition should, like the example of the MoH, acknowledge the structural aspects, such as the resource constraints. Otherwise, if every care would be considered as disrespectful, if the global standards are not met, a prevalence of 100% disrespectful care would be measured (Ibid., 915). In addition, they
8 highlight the problem of normalisation. If the definition is only based on what women and providers experience as violations, the definition will be too limited since some aspects will not be regarded as violation because they are expected and accepted (Ibid., 916). Thus, general standards remain important, as shown in Freedman’s model (See figure 1).
While keeping these two definitions and the by Freedman mentioned problems in mind, I underline Rosen’s doubt: “a particular concern for those conducting research on RMC and D&A is how to determine which events or situations qualify as respectful or abusive” (Rosen et al 2015, 9). Instead of choosing a disputable definition, I recognise the importance of Freedman’s model in which different levels of abuse are separated: a core of behaviour that all agree upon as disrespectful, levels of normalised disrespectful behaviour, and behaviour influenced by structure or policies (Freedman et al 2014, 916).
Freedman’s study underlines that the structural and cultural environment influences the quality of care.
In this study, I aim to unravel midwives’ perceptions on RMC in order to understand their view on sociocultural, structural and emotional influences. I conducted a qualitative research involving extended observations, small-talk, and semi-structured interviews in an urban and peri-urban facility to broaden our knowledge about the causes for disrespectful care. The research question that guided me in this research is: How can we understand the occurrence of so-called “(dis)respectful” care in maternity wards in Malawi? I focused on the following sub-questions to answer this question:
1. What facilitates or hinders midwives in delivering (dis)respectful care in maternity wards in Malawi?
2. How do midwives perceive their work in maternity wards and how is this influenced by structural, socio-cultural, and emotional aspects?
3. How does training on RMC seem to influence the perspectives and practices of midwives regarding (dis)respectful care?
To do justice to midwives’ perspectives and highlight aspects that have not been elaborated on in earlier research, I will approach these questions with two theoretical lenses: ‘ethics of
9 Table 3. (Source: WorldBank 2016)
care’ and ‘emotional labour’, but first I will elaborate on background information of Malawi and how RMC has been approached previously.
Malawian context
Healthcare system
The Ministry of Health is responsible for 60 percent of all healthcare, and provides free, public health services (Mangham 2007, 5). The private sector, consisting of faith-based organisations (e.g. CHAM), NGOs and for-profit clinics, provides around 37 percent (SHOPS-project 2012, 4), traditional healers and birth attendants also provide a small percentage of healthcare (Mangham 2007 , 5 ).
The health services provided by the government, consist of three levels. Primary healthcare meets the primary needs in rural hospitals and health centres (MoH 2011, 90). Patients can be referred to the second healthcare level where more specialised care is provided, for example in district hospitals (Ibid., 90). The tertiary, highly specialised care, can be provided in four central hospitals (Ibid., 91). All these three different levels, face a shortage of material and human resources.
Shortage of Resources
Malawi’s human resource shortage is severe, even by African standards (Mangham 2007,1). An Emergency Human Resource Plan (2004-2009) was implemented to improve this situation (Ibid, 15). Despite US$53 million investment on capacity building, the human resource shortage stays critical (Ibid., 38). Table 3 illustrates that Malawi experiences extreme shortages, even compared to the nurse-midwife density in neighbouring countries (WorldBank 2016a,b). The Ministry of Health (MoH) recognises the lack of equipment, facilities, and qualified human resources as hindering factor for improving the quality of care (MoH 2011 , 50).
The working conditions of healthcare workers, broadly influenced by this lack of material and human resources, seem to influence the motivation and job satisfaction which Mangham argues is related to poorer quality of care (Mangham 2007, 8 ). A study about the
10 lives of Malawian nurses shows that nurses experience frustrations about the extreme lack of resources, high workload, and low salaries (Grigulis et al 2009 , 1 196). Lugina argues that this pressure can increase stress and demotivation (Lugina et al 2002 , 1 9 ). In chapter four, I will use the theory of emotional labour to understand these feelings and its influences on care practices.
Socio-cultural context
Malawi is considered as one of the poorest countries worldwide (Mkandawire-Valhmu et al 2009, 7 87). The Human Development Index positions Malawi at place 173 out of 188 countries (Human Development Report 2015, 2 ). Estimates show that at least 72 percent of the population lives below the international poverty line of $1.25 a day (Ibid., 7). Education attendance and level is low; 58,6 percent of women were literate in 2015. On averages, people above 25 years old attended school for a maximum of 4,3 years (UNDP 2015). A study in South-Africa among nurses indicates that power differentials between educated nurses and uneducated patients can lead to patients’ inferiority (Jewkes et al 1998, 1781;1790). Wendland recognises in her ethnography that these dominant power structures also occur in Malawian context (2010, 8;12). In chapter three, I will analyse power imbalances between midwives and patients.
Wendland also links these power imbalances to Malawi’ colonial history. Livingstone, a famous missionary from Scotland, emphasised the importance of medical missions (Wendland 2010, 40). These pioneered in founding rural hospitals and training health professionals such as midwives (1991, 56). This means that the Malawian health system was developed according Western standards (Smit 1998, 4 ), in which health professionals were seen as dominant over patients (Wendland 2010, 38). Jewkes and colleagues (1998) also use the colonial history as part of an explanation of abusive behaviour against delivering women. Historically, nursing was a job only for elites, which can explain South-African midwives’ authoritarian position (1998, 1782).
Cook and colleagues conducted a study in Malawi and underline the idea that “health systems are social in nature” and are influenced, as discussed earlier, by staff shortage, but also by relationships, expectations about job roles and power dynamics (Cook et al 2016, 7). My chosen theories to approach RMC, will help to illuminate structural and social aspects influencing RMC.
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A human rights-based approach
Human rights in anthropology is characterised by an ambivalent relationship and different critiques and methods to approach human rights were articulated (Goodale 2009, 18). One of the well-known critiques is that of cultural relativists; they argue that the universal principles in human rights are not attending the cultural particularities (Kelly 2010, 393).
In 1999, the American Anthropological Association declared that “anthropologists have a disciplinary obligation to use their research expertise to expand the definition and meanings of human rights…” (Goodale 2015, 362). Ethnographers started to approach human rights in practice, which goes beyond universalism and relativism. In this way, it can be investigated how various social actors understand and apply, or reject certain universal claims (Wilson 2006, 78).
Some proponents of a human rights-based approach (HRBA) seem to deem RMC as universal. I do aim to investigate how social actors, in this case midwives, understand and apply RMC, but not by explicitly focussing on the universal human rights claims. I want to avoid a HRBA when investigating RMC, for two reasons. First, I argue that the HRBA sees respectful and disrespectful care as if these are absolute and mutually exclusive categories. This indicates that care is reduced to a dichotomy instead of approached as a continuum. I will show in chapter three that there are practices that opposite each other, but that there are many care practices that are somewhere in the shades of grey in between.
Second, I argue that a HRBA can be seen as a top-down approach, based on universal principles, that are imposed on midwives to improve the quality of care. Therefore, this approach lacks attention for the context and situatedness in which care is provided. This has two consequences. First, it leads to a lack of attention for midwives’ abilities and limitations in providing RMC. Because midwives are seen as responsible for providing respectful care, they should be able to change their practices. Pettersson and colleagues show, however, with their study on Mozambican midwives’, that they do not feel empowered to promote change (2006, 158). Second, by disregarding the contextuality, the HRBA not only forgets to look at the feasibility, it also ignores the desirability of certain care practices. Only when specific care practices are desired in a Malawian context, they are pursued. So, investigating midwives’ perspectives, their local understanding of the problem, and their extenuating circumstances, can illuminate barriers they face in delivering RMC and help to come to locally sensitive interventions.
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Literature review on RMC: critique and inspiration
In studies on RMC in Malawi and neighbouring countries, different approaches have been used. The cross-cultural study in five African countries of Rosen and colleagues (2015), for example, adopts a HRBA. They made use of a delivery observation check-list, based on the seven rights. For each right is mentioned, how the obtained data indicate if this right is violated or not. They seem to condemn midwives based on the violation of such rights, without acknowledging the circumstances in which they provide care. Other studies are less condemning but they do use the seven rights to present their findings (e.g. Okafor et al 2015).
There are other studies conducted that do take the context into account. For example, in Malawi. Kumbani’s study (2012) focusses on women’s perspectives regarding RMC. They conclude that these women have low expectations and are therefore not critical regarding the quality of care they receive. Kafulafula and colleagues (2005) focus on safe motherhood and conclude that only a multi-sectoral approach will help to decrease the high maternal mortality ratio in Malawi. This study does not elaborate on RMC, but shows the challenges midwives’ face (2005). Bradley’s team (2015) also elaborates on these challenges and reveals the difficult circumstances in which midwives try to provide respectful care. They conclude that this exacts emotional toll of the midwives. De Kok (2014) advocates for understanding midwives’ practices rather than condemning the care provided by midwives. This argument has been an inspiration for my focus, because I also intend not to condemn the practices of midwives, but use their perspectives to understand the sociocultural context in which they provide care.
In neighbouring countries such as South-Africa, Mozambique or Kenya, studies tried to highlight drivers for disrespectful care (e.g. Jewkes et al 1998). Some authors use structural and cultural aspects as explanation for the way midwives provide care such as lack of human resources and low salaries (e.g. Pettersson et al 2006), and issues of power dynamics and maintaining control (e.g. Brown 2010). Jewkes study in South-Africa for example, argued that patients who do not obey midwives’ instructions are punished in order to maintain midwives’ control and underline their status (1998, 1793).
Previous mentioned research of Petterson (2006) also inspired me for my focus. Petterson gives much attention to the working conditions of nurse-midwives in Mozambican hospitals: “The task of practicing midwifery in low-income countries appears to be more difficult than ever, particularly in Africa where resources for maternal healthcare services are limited” (Pettersson 2006, 146). According to Petterson, the working conditions of midwives appear a key-predictor of stress (Ibid.), and can lead to frustration, demotivation,
13 dissatisfaction, and dehumanisation (Mangham 2007, 7-8). Bradley and colleagues also acknowledge midwives’ emotions (2015, 7). These studies suggest that emotions matter, but never explained why. My focus can provide an exciting opportunity to advance our knowledge of the role midwives’ emotions play.
In this thesis, I will first elaborate on the chosen study locations and used methods, including the limitations and ethical considerations. Chapter three and four are empirical chapters, in which I start with a discussion and explanation of my theoretical approach, followed by my findings. Chapter three discusses the ethics of care, which helps to create awareness that care is cultural and context specific, which underlines that a universalistic HRBA is not sufficient to understand quality of care. Chapter four, in which I elaborate on emotional labour, will highlight the difficulties of delivering empathic care in the Malawian context, and that midwives’ feelings should not be underestimated in their influence on care practices. I will conclude this thesis with a discussion of my key findings, as well as elaborating on limitations and recommendations for further investigation.
14 2. Methodology
To gain insight into care practices and midwives’ work experiences, I combined participant observations and semi-structured interviews, to see what was going on and hear midwives’ inside descriptions about what was happening. Since I have focused on activities in and around the maternity ward, my research can be categorised as hospital ethnography. In such ethnographies, is recognised that “hospitals both reflect and reinforce dominant social and cultural processes of their societies” (van der Geest & Finkler 2004, 1995). It is therefore a way to illuminate cultural and organisational aspects in hospitals (Gerrits 2016, 32). This is important because the quality of care, and midwives’ experiences and behaviour will be influenced by the hospitals’ culture, setting and organisation.
In this chapter, I will discuss how I obtained access in and elaborate on the two chosen facilities, which methods I have used and how I analysed the produced data. I will discuss limitations, challenges, and reflect on ethical considerations and my position as researcher.
Getting access
The National Health Sciences Research Committee of Malawi had given ethical clearance to the Edinburgh Project in which I collaborated. This project already worked in close collaboration with AMAMI. The Project Leader of AMAMI helped to facilitate a letter from the District Nurse Officer (DNO) of Lilongwe.
Because qualitative research aims at generating information-rich cases (Green & Thorogood 2014, 166), I selected two different types of sites which enabled me to spend much time in each site. These sites must have been incorporated in the districts where the training sessions about RMC were provided. In consultation with the Scottish research team, I chose for an urban facility, Chachikulu1 District Hospital, since it was easily accessible and I
could experience a lot while doing observations because of the large setting. I chose to combine this with a smaller, peri-urban facility, Zochepa2 Health Centre, to have a more representative impression of labour wards in Malawi. Both sites were willing to participate after I showed the DNO’s letter and introduced myself and the research.
Study Location
Chachikulu Hospital, is a district hospital that receives many referrals from health facilities in the surroundings, of which one of them is Zochepa Health Centre, that offers primary care.
1 Pseudonym; translation for ‘large’ in Chichewa 2 Pseudonym; translation for ‘small’ in Chichewa
15 The following numbers are important to create an image of the two research locations (Table 4).
Chachikulu District Hospital
Chachikulu Hospital is located in the capital city of Malawi. The maternity wing in this hospital is separated into different units: a nursery, antenatal, high-risk postnatal, low-risk postnatal and labour ward. There is also one theatre room. Every ward has its own matron and a team with nurse-midwives. In the labour ward, on which I focused, are the nurse-midwives divided into 4 teams of around 8 people. Because I wanted to engage with the midwives and create a relationship with them, I decided to focus on two teams; team B and team D. Every team had a team leader, but their tasks did not remarkably differ from the other midwives. During the week, there were also three nurse-midwives in charge. They expressed in the interviews that they wanted to function as role models and corrected misbehaviour of colleagues or negotiated between colleagues when there was a disagreement. In addition, they also had a key of the spare room and made sure the equipment was used properly and ordered in time. They also called midwives who did not come for duty or call for locum to assist during critical shortage of staff.
The 8 nurse-midwives are assisted by hospital maids who do cleaning tasks. Clinicians and intern-clinicians were also working in the labour ward, who could be consulted when there was a complication. During the period that I did my fieldwork, most of the times there were 4 to 5 student nurse-midwives assisting in the labour ward. They were allowed to do everything on their own but a qualified nurse-midwife could be called for assistance or supervision. The students, doing a short internship, helped to decrease the workload. During the day and nightshifts there were the same number of nurse-midwives allocated. In practice, it was rare to see all 8 team members present.
The labour ward consists of a big hall with a nursery station and a large round desk. There are 10 different labour rooms connected to this hall. In most of the rooms are two beds. Between two labour rooms there is a small bathroom. See figure 2 for the setting.
16 Zochepa Health Centre
Zochepa is located in a village, 30 km out of Lilongwe. It serves a large area of surrounding villages. The heath centre has an ART clinic, out-patient department, and maternity wing. The nurse-midwives working in the maternity wing divide themselves over the different tasks and combine them when there is a shortage of staff.
In principle, they serve the antenatal women that come for check-ups around three to four times before their delivery; provide postnatal check-ups after one and six weeks after the delivery; serve as out-patient department for pregnant women and women who delivered within three months (for example for malaria tests and medication); provide family planning and conduct deliveries. In a separate small building is a waiting house for pregnant women that come from far, so they can come up to nine weeks before their delivery. This encourages that women will come to the facility in time, instead of delivering at home or on their way to the facility. See figure 3 for an illustration of the maternity wing.
17 There are 11 nurse-midwives employed in the
maternity wing. During the week, they are supposed to be with 6 nurse-midwives, and during the weekend with two. The nightshifts are always done by one nurse-midwife, who receives assistance from a hospital maid. These are also available during the days for cleaning work and preparation of equipment.
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Methods
Observations
In the two main sites, I started my fieldwork with doing observations. In both facilities, the matron oriented me, which functioned as a ‘grand tour’ for me to observe the field, which provided a first impression of the setting (Spradley 1980, 77-78). I started small talk with midwives, and followed their activities. Observations gave me the opportunity to see the practices performed by midwives, the interaction with patients and other healthcare workers, and their working environment and conditions. It also helped to build a good relationship with my participants. I attended full day shifts during working days and weekend, as well as three nightshifts. I followed different midwives and different activities such as deliveries, breaks and organisation of equipment in and around the labour ward.
In Chachikulu, I focused on the labour ward to see midwives’ work environment and activities, although arguably ANC and PNC are part of maternity care too. The hospital is, however, too big to include these wards. In the labour ward, I observed in different delivery rooms, the admission room, and the hall where the nursery station is and where they take breaks and interact with each other.
In Zochepa, I had to broaden my view. This facility is smaller and the nurse-midwives working there, do not only conduct deliveries. I could not only focus on the labour ward since almost all afternoons, there were no delivering women. Since my aim was to understand midwives’ work experiences and the care they provide, I followed these midwives also in their other daily activities.
In the beginning my participation level was low because I am not a midwife, clinician, or patient. As van der Geest and Finkler suggest, participation in hospital ethnographies is questionable (2004, 1998). My position shifted, however, during my fieldwork to a more participant observer. In Chachikulu, my participation was limited to assisting in organising equipment, handing or searching equipment and resting together on a mattress on the floor during a nightshift. In Zochepa, my participation level rose to a high degree. I have been there on days that the shortage of staff was immense. I could help in making documentations, getting materials, and measuring vital signs such as blood pressure, temperature, and weight.
I felt more comfortable when I could assist than by only observing, since I felt less of a burden to them. It also helped to ask their time for explanations because I gave something in return. In addition, this participation strengthened our relationship, since they appreciated it a lot. Finally, it contributed to see the practices through midwives’ eyes which helped to increase my empathic understanding of their experiences. I experienced for example that after
19 checking the vital signs of a few women, I started to do it as a routine and became kind of detached from the patient because I just followed the procedure which I had to do quickly due to the long queue.
Semi-structured interviews
After a few weeks, I started to conduct interviews with midwives in Chachikulu and Zochepa (See Appendix A for information about the participants). The observations helped to get a first impression about their work environment and care practices, so I could direct my questions more properly to what I observed. It also helped to build a relationship with the midwives, which facilitated an open atmosphere during the interviews. It may have given the midwives the feeling that I was not there to judge so they could share their stories. In total, I did 15 interviews with 16 midwives in these two facilities. One of these was with two midwives, because they preferred this after providing ANC together the whole morning. Two of the interviews were with students from Kamuzu College of Nursing who did a four-weeks internship in Chachikulu Maternity Ward.
I introduced the interview by explaining that my aim is to understand midwives’ perspectives about their care practices and work environment. I ensured that the information they shared, would stay anonymous and that they could skip questions or decline if they did not feel comfortable. I used a topic-guide (see appendix B) which helped to address certain topics; it structured the interview, which I deliberately started with easy and non-sensitive questions, to move towards more ‘difficult’ topics. I also asked about specific experiences of good and poor care practices. I presented myself as non-judgmental and explained that I would love to learn from them. I gave the interviewee the choice where to conduct the interviewee. This was mostly in an empty room. This choice could make them feel safe to share sensitive information.
In the beginning, I was less experienced in doing interviews and faced difficulties in probing about more sensitive topics. During the fieldwork period both the relation with the midwives, as my confidence to probe more improved, which might have influenced the outcome of the interviews. I also adapted and shortened the topic-guide a few times, by skipping some questions, which were also answerable by the observations. I felt more comfortable with a shorter interview because I observed midwives’ work pressure. All midwives who I asked were willing to participate.
20 Small talk
The many days I have been around in the two facilities, were also accompanied by hours of small talk. It gave me the opportunity to ask for explanations about the practices they were doing. The interaction between mothers and midwives was always in Chichewa, which I do not speak sufficient to understand these interactions. I will reflect on this limitation later in this chapter. Sometimes the midwives translated things the mothers said, which was helpful to understand the situation better. The small talk helped to maintain a good relationship, to understand more of what was going on, and to get an idea about how the midwives were feeling. Especially expressions of their emotions were enlightening for my understanding how a situation made them feel, especially because they did not elaborate much on their feelings during the interviews. Feelings such as tiredness and frustrations were expressed often while doing their daily activities.
Data collection and analysis
During the observations, I minimised taking notes because this could make midwives more aware that I aim attention at them. This could distract them from their work or adapt their behaviour. I could enter and leave the rooms freely, so I took some time in between care practices to make some notations. Sometimes I put keywords in my phone, since phones were common in the wards, and nobody would realise I was taking notes. When I wanted to reflect on a situation and I had the possibility, I shortly isolated myself or went outside for a moment to make some remarks in my notebook. After a day or nightshift, I typed everything as soon as possible to put the detailed memories into words.
When typing my observations, I deliberately separated a section with my observations from a section how a situation made me feel, to be as objective as possible. These notes on emotions helped in the interpreting phase, to remember the exact situation.
Atlas Ti, a qualitative analysis programme, helped to group and analyse my large collection of data in a structured way. I placed ‘open codes’ to categorise the data. This is a strategy to take a step back from the data and describe what is going on in that particular phrase (Green & Thorogood 2014, 235). I used both descriptive as conceptual codes. This helped to create broader themes such as ‘poor care’ and ‘consequences of shortage of staff’. In a later phase, this programme helped to see relations between codes and easily find quotations or vignettes about specific situations.
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Limitations
All methods have their limitations, so reflection is needed. For my observations, a first limitation was that I do not speak sufficient Chichewa to understand all conversations. This was for example difficult when the midwife was raising her voice to the patient: depending on what she was saying it could mean she was harsh to her patient or it could mean that she was strongly encouraging the mother to push. This is a limitation, but I do not have the impression it influenced my data too much. I could focus on the non-verbal language and facial expressions, which made it most of the times clear what was going on. Awareness of this body language is essential, since it determines the meaning.
Second, in all participant observations, ‘reactivity’, or also called ‘observer effect’, among participants when interacting with the researcher is inevitable. The assumption is that participants could behave ‘better’ or ‘hide’ certain behaviour when knowing the goal of the research (Monahan & Fisher 2010, 358). This could be the case for midwives, since they are aware of my presence. However, because I was around for a longer period of time, it is assumable that midwives do not maintain possible ‘unnatural behaviour’ for a long period (McKechnie 2008, 730). In addition, they seemed to accept my presence: sometimes they invited me to join their activities, sometimes I asked to follow them to observe or sometimes I was in the neighbourhood and could see what they were doing.
Another difficulty I faced when typing my observations, was putting my observations into words. I was not familiar with medical terms, so I did not know how to call certain equipment, medication, or procedures. But more importantly, certain practices were so captured in the setting that it was difficult to rephrase them into words. Intonation, facial expressions, and the intensity of gestures can make a big difference in experiencing and interpreting this as friendly or unfriendly behaviour.
A limitation of interviews is the well-known phenomenon of respondents providing socially desirable answers (Green & Thorogood 2014, 98). Especially during my three pilot interviews to test the topic-guide, I had the feeling they were not openly sharing everything, and were answering what they thought I wanted to know. Later, when I built a relationship with the midwives, and when I could refer to specific moments during the observations, it was easier to get passed the socially desirable answers. Still some inconsistencies between their answers remained or I observed something else than what they told me. I think this is due to the sensitivity of the topic, or the wish not to gossip about colleagues.
22 A last limitation during my fieldwork, was that I planned to do focus-group discussions but due to the lack of official breaks and midwives’ limited time, this was not possible.
Positionality
Because in qualitative research, “data are ‘produced’ rather than merely ‘collected’” it is essential to be reflexive about the role I played in generating my data (Green & Thorogood 2014, 24). My position as white, female student, has had an influence on my position in the field. That I am a woman made the access to the field easier; males are hardly allowed in the labour ward, except for male healthcare professionals. I have presented myself as student without experience in care practices, to underline the expertise of midwives. It was important to give them the assurance that I was not there to judge about how they provided care, but to constantly underline that I wanted to learn from them and understand their experiences.
The fact that I do not have any experiences with childbirth, or care practices of midwives, has also influenced my observations and interpretations. I did not know the standard procedures or protocols, so this made it easier not to judge about the care they provided. My experience with healthcare professionals in the Netherlands when I was a patient myself, however, did influence my expectation of how the interaction between nurse and patient would look like. This, combined with the image of nurses as friendly care-takers, led automatically to a kind of lens through which you approach the field. I have tried to observe as objectively as possible by describing in detail all practices, gestures, and intonations, and separated this from my feelings and interpretations. This prevented me of placing my perspective about how a nurse should behave, on the Malawian midwives, and it minimised judgements.
Ethical considerations
Researchers are responsible for the consequences their research may have on their participants and study location (t’ Hart et al 2009, 60). Therefore, I paid attention to the ethical aspects in the preparation of my research and during my fieldwork. Because the ethical guidelines did not always correspond with reality, continuous reflexivity and awareness of the possible consequences was needed.
A positive consequence was midwives’ opportunity to share their stories and work experiences. They appreciated my interest in their perspectives. In addition, this research could ideally in the future contribute to a better understanding of midwives working
23 conditions and improve RMC. But as Gobo states, there are always potential risks for participants (2008, 142).
Complaining about working conditions or admitting patients’ abuse could be risky for midwives. Therefore, I assured them of their anonymity and confidentiality and took the following measurements: I have used pseudonyms to assure anonymity and secured my flash and computer with a password. I have explained this to all participants before the interviews and asked them to sign an informed consent form. All of them agreed with being recorded and appeared satisfied with the precautions for their privacy. For the observations, I asked orally informed consent of the midwives. They have never expressed any concerns or doubts about the interviews nor observations, and were all willing to give me the opportunity to ask questions or follow their activities.
One of my concerns, was to get informed consent of the mothers who were going to deliver. In a meeting with the leader of AMAMI and the other researchers, we decided that it is necessary to have their consent. I agreed, but in practice this was sometimes difficult. This obstacle could not easily be solved, but at least reflection on it is needed.
First, I do not speak sufficient Chichewa to introduce myself to the mothers and ask permission. Therefore, I had to ask the midwife to introduce me and ask consent. Because the midwife does not introduce herself and is busy, it sometimes felt as a burden to ask her this. Some laughed when I asked them, as if they thought it was unnecessary to introduce somebody. It made me feel uncomfortable, because I also did not want to give them the idea that I am more important. To deal with this, I tried to emphasise that it was needed for the research to have their consent.
In addition to this first barrier, I had to trust the midwife that she explained properly, that the woman understood, and that the woman was indeed okay with having me there. Sometimes a midwife took her time to explain to the woman and the woman thanked me or agreed immediately. But there were also times that a midwife explained very shortly and that the woman hardly responded, even though the midwife told me that I was welcome. I will give an example from an observation in Zochepa, to illustrate this difficulty:
Diana introduces me, but the woman does not respond and looks confused. I am worried she does not feel comfortable with me being there. Diana says more things to her and repeats her question when the woman does not answer. The woman looks to me and then back to Diana and then again to me, back and forth. It seems like as if she is hesitating. Finally, she nods and Diana says it is okay. I ask Diana why she was in doubt and assure her that it is no problem with me to wait outside if the woman is not comfortable. Diana laughs and says that I should
24
stay. Laughingly she tells me that the woman is not educated and just did not understand what Diana was asking her. Diana explains to that when she told the mother that I was looking at the quality of care to improve this for women, that she then understood and was fine with it. I hope this is the case, I am doubting, but I have to trust Diana’s words. (Zochepa, Observation 8)
Because I could not understand what Diana and the woman were saying to each other, I had to believe Diana that the mother indeed agreed. If I had left the room because I had the feeling the woman was hesitating, I would have showed distrust in Diana, who assured me that I should stay. Related to this problem, is another difficulty, because I am uncertain if the woman would have dared to say ‘no’, if she did not feel comfortable. It seems that there is a great power difference between Malawian mothers and the midwives, so the mothers could therefore avoid saying ‘no’. They might be afraid it would affect the care they receive if they did not obey with a request of the midwife.
Then a last problem occurred in Zochepa during the nightshifts when I already was in the labour ward and had permission of the women. A new woman entered and she delivers immediately; there was no time to ask permission, I was already there, and I was handing over some equipment, so it felt more inappropriate to suddenly leave the ward and stop my observation and my assisting tasks, instead of being there without permission.
The fact that the privacy of the women is already violated because so many healthcare professionals enter and leave without introductions, made it a bit easier to put into perspective the importance of full consent. I am, however, relieved that in most cases I was able to get consent because delivering a baby seems a very intimate moment in a mother’s life. All women that were asked permission agreed, which enabled me to attend many deliveries. This gave me the opportunity to observe a diverse sets of care practices, which helped to gain enough data for this thesis.
25 3. Care in Context and Culture
Before discussing the care practices provided by midwives in the maternity wings in the two Malawian health facilities, it is essential to have a certain framework to explore this care. How can we evaluate care? And can we differentiate between good and poor care? Scholars have different views on these substantial questions. They developed different perspectives and tried to conceptualise care, which led to different normative and theoretical positions regarding care giving, care receiving, the ethics of care, and the justice of care (Rummery & Fine 2012, 321).
Rummery and Fine (2012) argue that care has three unique aspects. First, care is based on emotions, because it builds on concerns for the well-being of others. This asks for empathy, recognition, and responsibility, to feel and answer the needs of the care receiver. Second, physical activity is involved in providing care; care is a form of labour to fulfil the needs of others. Third, care is understood as a social relationship. This relationship is often complex due to the power and dependency. These three linked aspects illustrate that care emerges as “both a complex and evolving social phenomenon and as an enduring and inspirational moral value” (Ibid.,323).
Care ethics recognises this complexity of care and its moral aspects, in which it is useful to understand care as practice. To interpret my data in this chapter, I use the theoretical frameworks ‘ethics of care’ and ‘care as practice’ (e.g. Tronto 1993; Held 2006; Mol et al 2010). This offers me another angle to approach RMC, to present my findings about relationships with patients and guardians3, and elaborate on ‘good care’ practices.
Ethics of Care
The theoretical framework of care ethics is relatively new in a long history of moral theories, nevertheless it has been highly influential (Held 2006, 9). It is important to underline that care ethics is a broad framework, and I cannot do justice to it here. I will use those aspects that will show the importance of this lens when studying the care that midwives provide in Malawi.
Carol Gilligan, ethicist and feminist, is usually deemed the founder of care ethics (Gallagher 2017, 56-57). She argued that there is a difference between ethics of justice and ethics of care (Edwards 2009, 232). The principles in ethics of justice, are based on rights and strives for equal treatment for all (Gallagher 2017, 56). Its universality and objectivity are central (Rummery & Fine 2012, 326). These values correspond to a HRBA, which I want to
3 Patients can bring a guardian, mostly family member (e.g. mother, mother-in-law, or sister) to provide basic care, such as bringing food.
26 avoid, as discussed in the introduction. I advocate for a different approach, because the Malawian context, which appears highly influential on care practices, needs to be considered to approach a problem such as disrespectful care. Ethics of care, as supposed to ethics of justice, does consider these contextual factors (Gallagher 2017, 56).
A distinctive and key feature in the normative heart of care ethics, is the relational focus (Held 2006; Collins 2015, 19). In these relationships between care givers and receivers, there is always a form of power and dependency (Collins 2015, 2). This dependency leads to obligations and responsibilities, that derive from within the relationship instead of from abstract rules. For example, a midwife providing care for a mother in the admission room, is dependent on patients’ cooperation; the patient is obliged to share her health history. The mother is dependent on midwives’ assessment; midwives’ obligation is to examine and decide which care is necessary. So, in this relationship, although the dependency may not be equal, both have their responsibilities. These responsibilities are not based on universal principles, but aim at attending to and meeting the needs of others (Held 2006, 9-10). Empathy - understanding and sharing another persons’ feeling - may be useful to feel what others need. Mol also highlights the importance of attentiveness in the logic of care, and thus the centrality of a relationship in care practices (2008, 85).
The ethics of care also distinguishes itself from other moral theories by valuing emotions, that are central in relationships (Held 2006, 10). Because of the value of these emotions, Held argues that care is a form of labour which cannot be performed by machines because then the relational aspect would be absent (Ibid., 36). Held continues with arguing that in ethics of care the interest of both care givers and care receivers are intertwined, and that care ideally promotes social bonding and cooperation (Ibid., 15). Social bonding might be relevant in creating a strong interpersonal relationship which is based on mutual attachment culminating in responsibility and attentiveness. This cooperation is not always guaranteed and reciprocity -which normally exhibits in relationships outside care- is especially in the relationship between nurse and patient not always present or fully balanced. Often, the care receiver asks more from the care giver than the receiver can give in return in forms of appreciation. The care provider does not always give the care that the care receiver desires, and the appreciation of the care receiver does not always occur (Dunn & Burton 2013). I will elaborate later on these aspects of social bonding and reciprocity that are important in hierarchical Malawian culture.
Tronto, an American political theorist and feminist, argues that this appreciation may be lacking because care is being devalued in American society (Tronto 1993, 179). This
27 appears to apply to Malawian context too. She pleas for more attention for the care provider because care deficits can occur when the needs of the care provider are not met or the work environment is not conducive. Tronto states: “care-givers are often enraged about their own unmet needs. If they are unable to recognise this rage, care-givers are likely to vent their anger on those for whom they take care” (Tronto 1993, 143). Others also linked care deficits and working conditions: “we need to provide care givers the conditions that allow them to do their work well and receive just compensation, compensation that matches the intensity of their labour, and encouragement in their sympathetic and empathic responses to their charges” (Kittay 2002 in Gallagher 2017, 62). These emotional and structural aspects that influence midwives’ care practices will be elaborated in chapter four.
These perspectives of Tronto and Kittay, help to move away from blaming individuals to giving more societal and political explanations when care providers do not provide care in an ‘ethical way’ (Gallagher 2017, 62). This is what I intend to do with the theoretical lenses ethics of care, and in following chapter emotional labour. I argue for the importance of taking organisational, relational, and contextual influences into account instead of judging practices provided by midwives.
Care as Practice
In care ethics, there is place for the recognition of the importance of caring practices (Tronto 1993, 108), which focuses on the situatedness and contextuality of care (Klaver et al 2014, 757). This contextuality means that sociocultural, political, organisational, geographical, and historical factors are considered. Situatedness then, recognises that a situation, for example a facility-based delivery, in which care is provided, is embedded in, and derives its meaning from this context. Care ethics therefore underlines that care needs local validation of meanings (Ibid., 759). This centrality of care practices asks for an empirical turn in the care ethics, which is characterised by a shift from a focus on applying abstract ethical principles to complex situations, to an interest in everyday ethical issues and how care givers deal with these in practice (Willems & Pols 2010, 161). Pols indicates that this empirical turn means that judgements about care practices from outside are meaningless and ineffective (Pols 2014, 83).
A common, critical argument of universalist on this idea, is that although different societies may have different moral practices, there still are fundamental moral principles beneath those practices, that can be regarded as universal moral standards. I recognise that there can indeed be practices that could be regarded as universally morally wrong, however,
28 refraining from judgements based on outsiders’ perspective (etic), creates space for understanding insiders’ perspective (emic). If seeking to understand care, it is not valuable to impose my etic judgements, based on my moral standards, whether care is provided in a good or bad way. Instead, it is valuable how such practices are perceived, categorised, and explained in Malawian context, since these interpretations will drive midwives’ actions. Therefore, I approach good and poor care by asking midwives’ perceptions. I use their views, that are incorporated into the specific culture and organisation, to assess the care practices I observed. This means that I temporarily set aside the universal moral principles in behalf of the analysis, although I recognise that these come back in the training sessions about RMC. But to make this training useful, first, the local meanings about respectful care need to be understood.
In this way, I do justice to Willems’ and Pols’ plea: “studies should not start from a pre-conceived idea of what the ultimate good is and what ethics is about, but should be sensitive to the goods that people involved in healthcare practices find important” (2010,162). They argue that defining what good care entails should be prevented, but instead should be studied empirically (Ibid., 166). Mol echoes, that care is invented and shaped in everyday practices, so it is not an ideal that can be defended in universal terms (2008, 5).
Brown applies this empirical turn in her study on midwifery care in Kenyan hospitals, and shows that nurses’ practices have strong correlations with practices in other social settings (Brown 2010, 130). She illustrates that for example children and wives are slapped to make them perform their specific roles, in the same way patients are slapped, not to hurt them but to help them perform their role as patient (Ibid., 134). She argues that by understanding these practices within a certain culture is helpful because “it contextualises a range of practices which from outside might be classed as abuse, but in this context, are not” (Brown 2010, 134). I will use care ethics to understand midwives’ perspectives on their care practices. This helped to move away from the universalistic HRBA which is dominant in RMC literature, research, and training, as in the case of the Scottish project this study is part of. Care ethics offers a more holistic view than used in a HRBA, because it recognises that good or respectful care is not a universal principle that can be defended, but something that is invented and shaped at all times in every practice. Care ethics calls for attentiveness not only for the personal context, but also for the cultural, social, and political context in which care is provided (Barnes 2012, 123).
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Relationships with cooperative and uncooperative patients
Since care ethics is a relational ethics, I will now discuss relationships with different ‘types’ of patients in Malawian hospitals. This can help to understand the context of the care practices performed by midwives, since it seems to influence the quality of care (Gastmans et al 1998). I will examine these relationships and midwives’ view on what makes a relationship ‘good’ or ‘bad’. I will link this to previous discussed theory, regarding responsibilities, dependency, and power, as well as cooperation and reciprocity. I will pay particular attention to ‘uncooperative patients’ because midwives mention this category of patients as affecting the quality of their relationship.
Communication, openness of the patient, and cooperation were commonly mentioned practice which made midwives perceive their relationship as good. A patient was perceived as cooperative when she followed midwives' advice, for example to empty her bladder or ambulate4; when she waited with pushing till the midwife said she was ready; or when she placed her legs as the midwife instructed. Some midwives also mentioned that their relation is good because they never heard a complaint from a patient or received appreciation such as:
“With the patients as for me it [the relationship] is very good. I interact with them very well and at the end they say, ‘thank you I like you’.” (Student-midwife Mimi 5,
Chachikulu).
Reciprocity was argued by Held (2006) as important in a caring relationship, but limited, because the care receiver is highly dependent on the care provider and cannot always equally give something in return. My data indicates the same. Some midwives expressed to miss a sense of appreciation for their caring practices. They mention that there are only a few patients that do appreciate, but that most just come and go:
“Others they don’t appreciate. They just see that whatever you are giving at them is not good at all.
Interviewer: And how does that make you feel?
Jah, (sighs) we feel bad. We don’t feel good. If, like maybe we are failures… Jah that also makes us not to continue maybe doing that to others because, it is a negative feedback from the clients themselves. So, it affects us. Even the care that we can provide to the others. It gets affected.” (Midwife Celina, Zochepa).
This shows the importance of reciprocity for the quality of care, because midwives explain to feel demotivated if they do not receive appreciation, which even can cause erosion of good
4 Mothers are encouraged to walk around, to create pressure on the cervix. 5 All names are pseudonyms.
30 care for other patients. In care ethics is recognition for the ideal of reciprocity, social bonding, and cooperation in a relationship (Held 2006, 15), which seems absent in midwives’ relationships with patients.
When there was no cooperation, midwives reflected on this as having a poorer relationship, and it was mentioned as cause for disagreements and conflicts. They had different views and explanations on which patients were less cooperative. The primigravidas6 were mentioned as uncooperative because they do not know what is going to happen and they fear the pain. The midwives explained that they do not follow their instructions, but do what feels right for them. The grand-multiparas7 were perceived as uncooperative because they know what to do and want to do it in their own way, so they don’t listen to the midwife. Education level was also mentioned as cause for uncooperating practices, which corresponds with findings of Jewkes and colleagues (1998), regarding social status and class, which midwives try to reproduce. Some expressed that the lesser educated were more difficult to take care of because they did not understand and therefore not follow midwives’ instructions. Others said that the higher educated were more uncooperative because they assume they know everything and deserve more, and therefore did not follow midwives’ orders. It appears that they all mention the same cause for disagreements, namely uncooperativeness of the patient, and so refer to this as not having a good relationship.
These relationships remind us of the well-known Parsonian model of the ‘sick role’, in which the patient is expected to cooperate in the process of getting well. This requires being passive and showing dependency upon the doctor (Segall 1976, 164). This dependency and need for cooperation seems also visible in a patients-midwife relationship. Collins argues that in care ethics, the caring relationships are often characterised by power imbalances and dependencies, that are accompanied by obligations for both care receiver and provider (Collins 2015,7). The interviews also point the importance of midwives’ power and status. Look for example at the following two quotes:
“Jah, disagreements are there because of, uhm, because those people they have maybe their beliefs. Like sometimes they, you tell them to do something else but they don’t want to listen” (Midwife Simone, Zochepa).
“There could be conflicts where then the midwife gets stressed and is tired and thinks ‘I am done with this patient and I don’t go to her again, she is not listening
6 A woman in her first pregnancy
31
to me’. So, it is quite stressful and even the patient’s guardian does get stressed
…” (Midwife Stephany, Chachikulu).
These quotations illustrate Simone’s and Stephany’s stance on the importance of listening to the midwife, which is reiterated by other midwives. It appears that patients that do not listen, are viewed as ‘uncooperative’ and ‘difficult’ patients. Midwives expressed different ways of dealing with such patients. Four ways of coping with uncooperative patients can be identified: Call the guardian:
“They [the guardian] can come and talk to her. ´Your patient, your client is not cooperative´. They will join. They will talk to her so they should cooperate with us.” (Midwife Oleta, Zochepa).
Explain the consequences:
“We just explain to them if they are not cooperative that they are the ones who are going to lose. Maybe … the foetus…” (Student-midwife Violet, Chachikulu)
Shout at the patient:
“But then they, some scream, you shout at them... You frustrating them. Saying that that will encouraging them, that that will make them afraid and then do.”
(Student-midwife Mimi, Chachikulu).
Abandon the patient:
“Sometimes if they come you just leave them to do whatever they want…Some want to lie on the floor. We just let them.” (Midwife Britt, Zochepa).
The first two practices were regarded as good ways to deal with uncooperative patients. The other two were often explained as necessary to make the patient compliant, although midwives realised that this is not the way as it is supposed to be done. They expressed, however, that in some cases they feel frustrated and they don’t know what to do otherwise, which triggers them to shout or abandon the patient. They use their feeling of frustration as justification for these practices. This corresponds with Jewkes’ research in South-Africa, in which midwives legitimated strategies such as slapping and scolding to gain compliance and control their patients. Jewkes’ also shows that midwives expect patients to be cooperative, humble, and accept midwives’ power, because the midwives are expected to achieve good patient outcomes (Jewkes et al 1998, 1790). The link between achieving good patient outcomes and cooperativeness of the patient was also made by midwives in my research.
The practice of abandoning the patient, has also been mentioned by Bradley and colleagues. They argue that to deny supporting a patient, can be seen as an effort to retain control and power, which acts as strategy for midwives to maintain their authoritarian position
