Copyright is owned by the Author of the thesis. Permission is given for a copy to be downloaded by an individual for the purpose of research and private study only. The thesis may not be reproduced elsewhere without the permission of the Author. MIDWIVES' USE OF UNORTHODOX THERAPIES: A FEMINIST PERSPECTIVE A thesis presented in partial fulfilment of the requirements for the degree of Master of Arts in Midwifery at Massey University CLAIRE LUCILLE HOTCHIN 1996 ii ABSTRACT In New Zealand independent midwives are increasingly incorporating unorthodox therapies into their practice. This research studied the experience of metropolitan midwives using unorthodox therapies within the existing medically dominated maternity care system. It also explored the forces that facilitated and constrained midwives in their use of unorthodox therapies. Feminist case study method was used to research the experience of five independent midwives who had integrated unorthodox therapies and practices into their midwifery practice. Their individual stories are related in separate chapters. Semi-structured interviews were used to gather the data which was analysed using the feminist concepts of power and gender. Three key points emerged from the analysis. The midwives strongly believed that the way in which they used unorthodox therapies in their practice benefited and empowered women . Secondly, they had some concerns regarding knowledge of unorthodox therapies. Thirdly, the midwives who used unorthodox therapies felt professionally vulnerable within the bio­ medical orthodoxy. Feminist theory was used to analyse the data and enabled the researcher to place midwives' use of unorthodox therapies within a broader socio-political context. It is hoped that this may stimulate midwives to examine their own use of unorthodox therapies as well as provide the impetus to initiate change within both the bio-medical orthodox maternity system and alternative heath movement. ACKNOWLEDGEMENTS My thanks to the midwives who participated in this study for sharing their experiences with me. Thanks to my supervisors, Val Fleming and Cheryl Benn. Val started me on my way and has continued to give me long distance, and much needed, feminist support. Cheryl has been a source of motivation and academic guidance. Thanks also to Jenny Carryer for her feminist input. iii To the midwives of the Midwives Collective with whom I work, thanks for your support both in my practice and my academic work, and for keeping midwifery exciting and challenging . To my friends, Robyn Kooperberg and Yvonne Hamer, who have actively and practically supported me by providing child care and encouragement giving me precious time to write this thesis, many many thanks. Love and hugs to my five year old daughter, Gillian, who has been extraordinarily tolerant of her mother spending hours and hours at the 'puter. Finally, my love and thanks to Jan Raymond, who has been wonderfully supportive throughout the process of this study. She believed in me when I no longer did. TABLE OF CONTENTS Abstract Acknowledgements CHAPTER ONE: Introduction and Overview Study context Aims of the research Theoretical framework Terminology Unorthodox therapies Woman/women Overview of the study CHAPTER TWO: Literature Review The increasing interest Midwifery literature Feminist literature Feminism and midwifery Nursing literature Medical literature Summary CHAPTER THREE: Method and Methodology Methodology Feminist theory Feminist research principles Reliability and validity Method Case study Descriptive multiple-case study Participant selection Ethical considerations Page ii iii 1 1 5 5 7 7 8 9 10 10 1 1 15 15 18 19 23 24 24 24 28 39 31 31 32 34 35 Data collection 36 Data Analysis 37 Case study 3 7 Gender 39 Power 40 Summary 41 INTRODUCTION TO DATA 42 CHAPTER FOUR: Judith's Story 44 Background 44 Integrating unorthodox therapies into practice 45 Understanding 45 Empowering women 4 7 Resources 47 Use of resources 48 Support 49 Reflection on practice 51 Expectations of midwives 51 Expectations of women 52 Reactions of orthodox practitioners 53 The political context 54 Working with orthodox practitioners 54 Hospital practice 56 Judith's input on her chapter 57 Summary 57 CHAPTER FIVE: Meredith's Story 59 Background 59 Integrating unorthodox therapies into practice 60 Openness of women to try 60 Offering options 61 No harm done 62 Reflection on practice 63 Homebirth as an unorthodox therapy 64 Decision points 66 Safety 68 The political context 69 Practice comparisons 69 Working with orthodox practitioners 71 Resources 72 Support 72 Midwifery practice as business 73 Meredith's input on her chapter 7 4 Summary 75 CHAPTER SIX: Brigld's Story 76 Background 76 Integrating unorthodox therapies into practice 78 Follow women's lead 78 Encompass family support 79 Supporting women's decisions 80 Empowering women 82 Reflection on practice 83 Orthodox clients 83 Unorthodox therapies and lifestyle 84 The political context 86 Cost to women 86 Political agenda 87 Brigid's input on her chapter 89 Summary 89 CHAPTER SEVEN: Adrienne's Story 91 Background 91 Integrating unorthodox therapies into practice 92 Partnership 93 Using communication as an unorthodox therapy 94 Empowering women 96 Usefulness of unorthodox therapies 97 Reflection on practice 99 Impact of the changing health system 99 Change in practice over time 100 The political context 101 Reclaiming midwifery 1 01 Model of practice 1 03 Minimal training 1 04 Criticism from orthodoxy 1 05 Protecting your livelihood 106 Adrienne's input on her chapter 1 07 Summary 108 CHAPTER EIGHT: Hiliary's Story 109 Background 109 Integrating unorthodox therapies into practice 110 Communication 111 Respect women's beliefs 112 Empowering women 113 Resources 114 Need for more information 115 Need for support 116 The political context 119 Vulnerability 119 Working with orthodox practitioners 1 20 Change 122 Challenging general practitioners 123 Midwifery practice 124 Hiliary's input on her chapter 125 Summary 125 CHAPTER NINE: Integration and analysis of data 127 Introduction 127 Three key points 1 28 Empowerment 129 Knowledge 134 Vulnerability 140 Implications for midwifery practice, education and research 143 Implications for midwifery practice 144 Implications for midwifery education 145 Implications for midwifery research 145 How the study has met its aims 146 Limitations of the study 148 Concluding statement 148 AFTERWORD 150 APPENDIX ONE 152 Information for prospective participants 152 Consent to participate in research project 153 APPENDIX TWO 154 Letter sent to participants with their draft chapter 154 REFERENCES 156 CHAPTER ONE INTRODUCTION AND OVERVIEW This study was initially conceived when I began independent midwifery practice in 1994. As a new independent midwife, attending home as well as hospital births, I felt immediate pressure to expand my repertoire of unorthodox therapies. I realised I was not sufficiently resourced in this area. I had been a hospital based midwife, both overseas and in New Zealand, for 16 years before I entered independent practice. It was evident to me that there was valuable knowledge and skills amongst independent midwives- skills and knowledge that were not valued or used within hospital settings. I wanted to know what these midwives knew. I was also curious about what midwives' experiences were of using unorthodox therapies within the larger bio-medical system. What influenced their decisions to offer unorthodox therapies to women? These thoughts led me to think about the use of unorthodox therapies by midwives from a feminist perspective. It was difficult to find any feminist critique of unorthodox therapies. This made me wonder whether midwives were in danger of uncritically replacing one form of oppressive orthodoxy for another. A study was born. STUDY CONTEXT New Zealand midwives are at the forefront of innovative midwifery practice world wide (Page, 1995b). Independent midwifery is established within our health system. Midwives can take responsibility for the care of women throughout pregnancy, labour, birth, and the post natal period. We can choose to give women midwifery only care1, or work in a shared care2 arrangement with medical practitioners. Independent midwives have admitting privileges to maternity hospitals and limited prescribing rights. Midwives have pay equity with medical practitioners. Many midwives work 1 . Midwifery only care means that all the antenatal, labour and birth, and postpartum care is given by midwives. 2. Shared care is care for women that is shared between two practitioners, most commonly midwife and gp or midwife and consultant. 2 within the New Zealand College of Midwives (NZCOM) midwifery model of care that has as its cornerstone the concept of partnership between midwives and consumers. A sophisticated system of professional review for all independent midwives is in place3. Midwifery education programmes, which are creative and contemporary, recognise midwifery as being distinct from nursing. To obtain midwifery registration, women have the choice of either direct entry programmes or post registered nurse programmes. Post registration university studies are also offered in midwifery at the undergraduate, graduate and doctoral levels. Page (1995b) believes we are in a position of leadership in the worldwide community of midwives. Midwifery in New Zealand, however, has not always been this strong. The 1904 Midwives Registration Act provided for the training and registration of autonomous midwives. However, as the 20th century progressed this autonomy was gradually eroded by the increasing political strength of obstetricians and their accompanying technology. By 1971 most midwives practised under the control of doctors in medically dominated hospitals. Consequently, when the 1971 Amendment to the Nurses Act legally ended autonomous midwifery practice and required that all births be supervised by a doctor, there was little reaction from midwives to this limitation of their practice. In most cases it made very little difference to how they had already been practising. From 1971 midwifery practice in New Zealand continued to be overwhelmingly controlled by the medical orthodoxy (Donley, 1986). Despite this medical domination, in the 1970s, there were a handful of domiciliary midwives (midwives who attend homebirths) nationwide who were practising outside the obstetrically controlled hospitals. In Auckland, in 197 4, there were two domiciliary midwives, Joan Donley and Carolyn Young, who each attended 50 homebirths each a year, although they also were required by law to have a doctor attend the birth. Domilicary midwives were paid by the Government but received a pittance for their work (a maximum of $76 per woman in 1975). They were seen as radicals by the medical establishment and received very little professional support. Nevertheless the demand from women wanting homebirths outstripped their ability to provide the services. 3. The Auckland region of the College of Midwives annually reviews independent midwives' practice. This is done face to face. The review panel consists of 2 consumers and 2 midwives. Consumers became their greatest supporters. By 1979 there were four domiciliary midwives involved in attending Auckland homebirths. They were now officially supported by the Homebirth Association that had been formed by consumers and domiciliary midwives in 1978 to combat the increasing medicalization of birth. 3 Domiciliary midwives used unorthodox therapies4 in their practice and many of the women they attended wanted these alternatives to orthodox medicine. Donley (1992) mentions the practice of domiciliary midwives, in 1979, of putting breast milk in a baby's sticky eye and giving a brew of kikuyu grasss for a urinary tract infection instead of a course of antibiotics. The women planning homebirths during this period wanted and expected midwives to use unorthodox therapies. Back in the hospitals the medical domination of midwives continued. During the 1980's, as the obstetrical control of childbirth in New Zealand grew, consumers joined together in other organisations throughout the country to fight the domination of midwifery by the medical and nursing professions. Groups such as the Save the Midwives Association and Parent Centre became politically active to raise the profile of midwives. Midwives also joined together and became politically active. In 1989 the New Zealand College of Midwives (NZCOM) was officially launchede . The NZCOM offered membership to both consumers and midwives thereby formalising the partnership between consumers and midwives that had developed over the previous 20 years. The NZCOM's major task was to continue the drive towards the independence of midwifery practice through amendments to legislation. The hard work of both the consumer groups and the NZCOM culminated in August 1990 when amendments to the 1977 Nurses Act gave midwives back their autonomy. At the same time midwives won pay equity with medical practitioners for comparable work. Suddenly it became 4. Seep. 7 for an explanation of the terminology used. 5. Couch grass 6. Previous to the NZCOM there had been a Midwives' Special Interest Section of the New Zealand Nurses' Association. The NZCOM was established separately from the New Zealand Nurses Association. financially possible for more midwives to leave the institutions and work independently with their own case loads. 4 Not many midwives were ready for this challenge. Years of medical domination had effectively undermined midwives' skills, knowledge and confidence. Midwives needed to learn new and innovative ways to practice. They needed to learn to work within the midwifery partnership model. Very few hospital based midwives had had the opportunity to use unorthodox therapies within their institutions. Nonetheless, many midwives who left hospitals for independent practice had years of experience, supported women's choice for non interventional childbirth, and were very woman­ focused in their practice. They came into independent practice eager to learn. New Zealand Home Birth Association statistics show that 1146 women in 1994 planned a homebirth. Of these births 1013 occurred at home. All the 1146 planned homebirths are included in the following statistics whether they birthed at home or in hospital. Forty eight percent of women had no procedures? in labour. Although not an unorthodox therapy, it is still unusual (and therefore unorthodox) for women to have a non interventionallabour and birth. Of those women who did have some procedure thirty two percent of women received homeopathies and 3.9 percent received acupuncture (New Zealand Home Birth Association Statistics, Spring 1995). Although statistics on unorthodox therapies, other than acupuncture and homeopathies, used are not presently available, the 1994 revised New Zealand College of Midwives review form (Auckland region) asks independent midwives to include all the therapies they use. Under the heading 'complementary practices' midwives will be able to document their use of homeopathy, acupuncture, water, massage, herbal remedies, aromatherapy or any other therapy. Once this data is collated it will indicate what therapies independent midwives are using and how often. However, I wanted to know more than the what and when. How were 7. Procedures collated were acupuncture, homeopathies, TENS machine, pain relief drugs, epidural, artificial rupture of membranes (ARM), oxytocin augmentation, episiotomy, and sutured laceration. 5 midwives learning about unorthodox therapies? What was their experience? How did midwives feel about their practice? Did other midwives also feel pressure to know more about unorthodox therapies? Were women asking for unorthodox therapies? How easy was it to incorporate unorthodox therapies into a midwifery practice within the orthodox system? I also had some concerns. From a feminist perspective the history of the bio­ medical orthodoxy is a story of the increasing control of women's bodies by the male dominated medical profession and the systematic undermining of both the knowledge and practice of traditional women healers (Donley, 1986; Morgall, 1993; Savage, 1986). I needed to know whether midwives, as they integrated unorthodox therapies into their practice, were looking critically at their practice. Were unorthodox therapies being substituted for orthodox therapies without any change to the underlying medical model? Were unorthodox therapies being used indiscriminately? Were they being used instead of good midwifery practice? In other words, I was interested in the process surrounding the use of unorthodox therapies, rather than what midwives used. AIMS OF THE RESEARCH 1. To make visible midwives' experience of using unorthodox therapies in the existing biomedical orthodoxy. 2. To describe some of the common unorthodox therapies midwives find effective and use regularly. 3. To explore the facilitating and constraining forces on midwives' use of unorthodox therapies. 4. To analyse midwives' use of unorthodox therapies from a feminist perspective. THEORETICAL FRAMEWORK This research is concerned with the experiences of midwives using unorthodox therapies as they care for women, often within the constraints of biomedical orthodoxy. Although some authors (Cooter, 1988; Sakala, 1988) believe that the increase in interest in unorthodox therapies is partly due to the 6 resurgence of feminism , a feminist perspective on the use of these therapies is lacking in either the feminist, nursing, or midwifery literature. The health system is a social structure which reflects the gender based organisation of our society with all its related inequities. Despite the fact that midwives work from a woman centred basis the reality is that they also work within the confines of the larger health system, which is medically controlled and patriarchal. Moreover, midwives' practice, formally and informally, is evaluated in at least two different ways- through the eyes of the medical model by institutional personnel, and by colleagues and consumers through the Midwifery Review Process. These two 'judges' often disagree about what is safe and informed midwifery practice. Such conflict leaves midwives carefully balancing their practice within the powerful biomedical orthodoxy. While midwives practice from a different model than those in the medical hegemony, they are still largely dominated by the biomedical orthodoxy. Some midwives also offer unorthodox therapies to women who want them. Many of the unorthodox therapies offered are not condoned by the biomedical orthodoxy. Using unorthodox therapies in midwifery practice under these conditions provides an ideal opportunity for feminist research. Jaggar (1994, p.11) states Our commitment to ending women's subordination inevitably leads us to confront complex, multidimensional problems that require us to balance a variety of values and to evaluate the claims and interests of a variety of groups or even species, including a variety of groups of women .... This in turn requires us to commit ourselves to seeking as many different perspectives as possible... We must find ways of hearing the voices of woman muted in the dominant culture, and we must respond to these voices by giving special attention and weight to the concerns they express. Midwives are women whose lives are worthy of examining as individuals and as people whose work is interwoven with other women. I am a white, middle class, middle aged, feminist midwife. This research stems from, and is part of, my own life as a woman, a mother, and a midwife. My 7 personal experience has been the starting point of this study and I have drawn from it to develop the questions, find my participants, and make choices and decisions about the direction of the research and the conclusions. As my personal experience is relevant to the research, I have written this thesis in the first person. As much as possible I have also allowed the participants to speak for themselves with the use of direct quotes. Presenting research in one's own voice counteracts the study's pseudo-objectivity and is a distinguishing feature of feminist research (Reinharz, 1992b; Webb, 1992). I was an 'insider' of the experience I was researching. Reinharz (1992a, p.260) describes this as a new "epistemology of insiderness" that sees life and work as intertwined. Childbirth is a feminist issue. The increasing use of unorthodox therapies in midwives' practice needs to be examined from a feminist perspective. All factors considered, a feminist approach seemed to be the most appropriate theoretical framework to use in investigating midwives' use of unorthodox therapies. TERMINOLOGY There are two labels used frequently throughout this research that require some clarification - unorthodox therapies, and woman/women. Unorthodox therapies, was considered, out of all the options, the most descriptive term to use in this research. This section gives background to that choice. The term woman /women can be problematic and so is discussed. Unorthodox therapies There is a wide variety of terms in the literature for therapies that stem from beliefs about the nature and causation of disease which are at variance with orthodox knowledge and practice (Aakster, 1989; Fairfoot, 1987; Gates, 1994; Jingfeng, 1987; McGinnis, 1990; Wolpe,1990). Prevalent terms used are alternative, complementary, marginal, traditional, indigenous, holistic, and quackery. Among these the two most common are alternative and complementary. Sometimes these are clearly defined as being different, often they are not, and are used interchangeably. Generally the term 'alternative therapy' is used when remedies replace conventional medical treatment and 'complementary therapy' is used when they work alongside conventional 8 medicine. Both these terms however, place the established medical system as the norm and define themselves in relation to it. Terms used in the literature for our established medical system include conventional, patriarchal, regular, official, cosmopolitan, modern, biomedicine, scientific, westernized, and orthodox. Wolpe (1990, p. 914) uses the term 'orthodoxy' which he describes as any institutionalized ideology. Bio-medical orthodoxy controls the health care of the western world . This ideology believes that western, scientific conceptualizations of the body and bodily processes are the only legitimate means to understand physiological functioning and disease. It also tries to prevent competing ideologies from obtaining an institutional foothold . This institutional foothold that has been achieved by the medical profession, has been greatly assisted by legislations. This legislation secured a monopoly by registered medical practitioners on certain practices, for example, full prescribing rights, hospital admitting privileges, and health insurance cover. Fairfoot ( 1987, p.384) contends Orthodox medicine and unorthodox therapies can be identified in society where there exists an occupational group whose job it is to apply therapeutic procedures to the sick and whose members display not only a high level of consensus concerning the causes of illness and appropriate treatments, but have also achieved legitimacy within that society as the approved healers. This study looks at midwives' use of both alternative and complementary therapies. I shall use the term 'unorthodox therapies' to include both unless I am specifically differentiating between them. Although tempted to use the term 'patriarchal medicine' for biomedical orthodoxy I have decided not to as I suspect that some unorthodox therapies are also patriarchal. Woman/women 'Second wave' feminism was based on the premise that the differences between women were less important than what united them - women are oppressed by men. Generalisations were made about women that ignored or 8. Medical Practitioners Act 1968. 9 denied their different experiences of sexism and oppression. While this has led to division in the feminist movement, it has highlighted differences between women involving class, race, mobility and sexuality. These differences are now being recognized as important and seeing women as united by certain characteristics is treated as essentialist (Coppock, Haydon & Richter, 1995; Stanley & Wise, 1993). However, Stanley and Wise argue that at this period in time in Western culture, women do share certain kinds of socially constructed attributes and are subjugated to and by men. This, they argue, continues to make 'women' a legitimate 'object' of enquiry. In this research I use the word 'women'. However, I recognise the differences amongst us and acknowledge that 'women' does not mean all women. OVERVIEW OF THE STUDY This study researches midwives' use of unorthodox therapies. My interest in researching the use of unorthodox therapies by midwives' arose when I entered independent practice. The following chapters describe the process of this research. This chapter has placed the study in a historical and current midwifery context. Aims of the research and the theoretical framework have been described. Two frequently used terms - unorthodox therapies, and women were explained. Chapter two introduces, discusses, and critiques the literature relevant to this study. Chapter three reviews the method and methodology used. The five chapters from four to eight are the case studies of five individual midwives. The case studies are made up largely of the midwives' own words but have been organized by me into theme headings. These themes were validated by the participants. Chapter nine integrates the data from the five midwives' case studies. This data is examined using feminist theory including the concepts of gender and power. Chapter nine concludes by discussing the implications of the research for midwifery practice, education and research. 10 CHAPTER TWO LITERATURE REVIEW This chapter provides a literature context to add further background to the research. The increase in the popularity of unorthodox therapies generally is discussed. Midwifery and nursing literature pertaining to the use of unorthodox therapies is examined. Critiques of alternative health practices and particularly unorthodox therapies are sought within the feminist literature. The relation of unorthodox therapies to the bio-medical orthodoxy is explored as it provides an understanding of how the dominant medical culture views unorthodox therapies and the practitioners who use them. THE INCREASING INTEREST Unorthodox medicine has grown in popularity over the last 20 years (Himmel, Schulte, and Kochen, 1993; Murray & Sheperd, 1993; Patel, 1987). There are many reasons put forward for this increased interest. They include, the public's increasing tendency to question the practices and decisions of doctors and care givers, more people attempting to live more 'natural' lifestyles, the belief in the benefits of self-help in all matters concerning health, and consumers growing dissatisfaction with the technological and scientific dominance of modern medicine (Himmel et al., 1993; Murray and Sheperd, 1993; Tiran, 1988). Wolpe (1990) and Sakala (1988) believe this increase in popularity has come about in part as an outgrowth of feminism and other social movements of the 1960's, such as the peace and environmental groups. During the 1960's people were encouraged to explore such phenomena as Asian culture, altered states of consciousness, and herbs, and to question authority. Orthodox medicine is fiercely resisting this trend to unorthodox therapies. Midwives and nurses, on the other hand, have welcomed this interest and are enthusiastically incorporating new therapies into their practice. 1 1 MIDWIFERY LITERATURE Midwives are showing a huge interest in the use of unorthodox therapies. However, while there are plenty of articles about unorthodox therapies related to midwifery, there is very little published research. Unorthodox therapies are just beginning to emerge in articles that discuss supportive strategies in labour. My study looks at the use of unorthodox therapies by midwives. No similar study has been found in the literature, although there is literature that includes some of the aspects. Three American studies are particularly relevant because they have looked at the unorthodox practices of independent (lay) midwives (Campanella, Korbin & Acheson, 1993; Sakala, 1988 &1993) . Lay midwives practice outside of the bio-medical orthodoxy and often serve distinct religious or ethnic communities. Campanella et al studied pregnancy and childbirth among the Amish. While they did not focus solely on midwifery care, they described some of the herbal remedies that the midwives relied heavily on. However the taking of vitamins, herbs and teas are also a part of non-pregnant life for Amish women so this midwifery care is not viewed as unorthodox. Sakala (1988) used grounded theory to study the content of the care that independent midwives gave to assist with pain in labour and birth in a fundamentalist Latter Day Saint community. The group of midwives studied were, because of historico-cultural traditions, exceptionally independent of bio-medical traditions. Sakala describes their practice as innovative. Their practice involved minimal intervention, a strong commitment to prevention and negligible costs for supplies, equipment, and facilities. Specific remedies and therapies that the midwives used are described throughout the paper. The article is exciting and inspiring to read. The midwives' content of care is contrasted to the bio-medical obstetrical model of care. Sakala concludes by recommending that these midwives' practices be formally evaluated for safety, efficacy, consumer acceptability, cost-effectiveness and their potential for favourable impact on the practice of medical obstetrics. The midwives in this study challenge our view of care in labour. Most of them described themselves as conservative and not politically involved, yet their practice is very unorthodox. 12 The second piece of research by Sakala (1993) was ethnographic and focused on midwifery knowledge and practice relating to circumstances that frequently result in the diagnosis of dystocia1 in routine obstetrical practice. Independent midwives who worked in home settings, also in a community Latter Day Saints, were interviewed. As in her other study the midwives' practice was innovative, flexible, and women centred. The midwives' sources of knowledge were derived from, and oriented toward, women's childbearing experiences. They felt obstetrical sources of knowledge relating to dystocia had virtually no meaning to their understanding of childbearing and midwifery practice. Sakala suggests that obstetrical sources of knowledge, that are derived from extrinsic and extraneous sources, legitimates professional control and management and invalidates women's bodies and experiences and the process of birth. The stresses of working in such an unorthodox way within the larger bio-medical orthodoxy is not explored in any of these three studies. Information sharing articles, usually on one particular modality are popular throughout the midwifery literature (Seal , 1992a, 1992b; Burns & Blarney, 1994; Dale & Cornwell, 1994; Fursland, 1992; Leigh, 1991; Schultze, 1994.; Smith, 1991 ; Stapleton, 1993; Swinnerton, 1990a, 1990b, 1991 a, 1991 b; Whitty, 1993). These articles tend to be focussed on aromatherapy and acupuncture, and are usually written by a midwife who uses the therapy in her practice. Articles that provide a general overview of unorthodox therapies in midwifery practice often include guidelines for practice, reasons for their use, a summary of the available therapies, cautions, and a call for more research (Budd, 1993; Spiby, 1993; Tiran, 1988). These articles are a useful starting point for midwives who are interested in incorporating unorthodox therapies into their practice. However they stop short of placing, and examining, the use of unorthodox therapies in the larger socio-political context. The only two research articles I found on unorthodox therapies in the midwifery literature were on aromatherapy. Burns & Blarney (1994) describe the results of their six month pilot study using aromatherapy in a delivery suite, although they do not draw conclusions about the effectiveness of the aromatherapy. Interestingly, they note that both the women and the midwives 1. Unacceptably slow or absent progress in labour as defined within the bio-medical model. experienced a high level of satisfaction in using essential oils. Dale & Cornwell (1994) researched the effects of lavender oil on relieving perineal discomfort on women postpartum. They found no reduction of postnatal perineal discomfort. More midwifery research on particular applications of unorthodox therapies is urgently needed to add to our midwifery knowledge and enhance our use of unorthodox therapies. 13 Recent midwifery literature has dealt specifically with coping strategies and supportive care in labour (Dancy, 1995; Gagnon & Waghorn, 1996; Hodnett, 1996; Simkin, 1995 & 1996). Despite the growing interest, unorthodox therapies are not automatically included with the strategies used by midwives caring for labouring women. Two North American authors (Gagnon & Waghorn,1996; Hodnett,1996) looked at the supportive care maternity nurses gave women in labour. Neither of these articles include unorthodox therapies. While both articles stress the benefits to women of continuous labour support, the support discussed is very mainstream. On the other hand, Simkin (1995) describes a wide range of non pharmacologic, simple, effective, low-cost methods to relieve labour pain. Some of the methods suggested are not in orthodox use but she believes they are effective and should be taught to caregivers. Dancy (1995) discusses a broad list of coping strategies for women having homebirths. She includes homeopathic and herbal remedies. These articles provide a useful source of supportive care, both orthodox and unorthodox, to midwives. The only piece of literature I found that investigated midwives' experience of unorthodox therapies was in a British book by Tiran and Mack (1995). It includes a section on midwives' attitudes to complementary therapies. Tiran and Mack interviewed 65 individuals, including midwives, on their attitudes to complementary therapy. The number of midwives interviewed is not specified, and the authors clearly state that these interviews do not constitute a researched study. They discuss some of the common themes the midwives spoke of. The midwives felt confused about the role of midwives and complementary therapies, especially what were they 'allowed' to do. It is not explicit whether these midwives were hospital or community based. Some of the midwives were concerned about their lack of competence to give advice, and lack of time to incorporate complementary practices into their routine 14 practice was identified as a major problem. The majority of midwives interviewed would have liked more training and knowledge in complementary therapies. They were also concerned about the qualifications of practitioners, and midwives' accountability, when they made referrals to other practitioners. Overall, most of the midwives were open and interested in the use of complementary therapies. They felt complementary therapies belonged in midwifery practice, and were not concerned how these therapies would be received by the doctors. However, we do not know enough about the midwives areas of practice to make a direct comparison with the midwives in this study. In New Zealand very little has been published on midwives' use of unorthodox therapies. Yet courses run especially for midwives, by homeopaths and acupuncturists are advertised in midwifery journals. Herbal remedies, homeopathies and essential oils are sold through the same pages. Midwives are obviously using these products, attending the courses and practising what they learn. The Auckland Home Birth Association has published a useful guide to healthy pregnancy and childbirth. This publication suggests a wide variety of unorthodox remedies and treatments for women to try should they need. This book which is used by both midwives and consumers is user friendly and well referenced (Auckland Home Birth Association , 1993). There has been no research to date related to midwives' use of unorthodox therapies in New Zealand. Despite this lack of New Zealand literature, recent New Zealand midwifery and childbirth conferences reflect in their programmes the growing interest of both midwives and consumers in these therapies. Workshops given by experienced practitioners have featured aromatherapy, homeopathy and acupuncture, and chiropractic care (Anthony, 1993; Donley, 1994; Funnell, 1994; Hudson,1993; Muller, 1994; Nash, 1993). While most authors advise more qualitative research into unorthodox therapies, they stop short of suggesting a feminist approach. However, there is an urgent need to include a feminist perspective on our use of unorthodox therapies in midwifery practice. A general review of the feminist health literature provided little that dealt directly with unorthodox therapies. 15 FEMINIST LITERATURE Although some authors believe that the increase in interest in unorthodox therapies is partly due to the resurgence of feminism, a feminist perspective on these therapies is sadly lacking in either the nursing, midwifery, or feminist literature. In a brief paragraph at the end of her book on feminism and women's health care, Webb (1986) comments that homeopathy, acupuncture, and other 'holistic' treatments can be as exploitative to women as orthodox medicine. This is the only feminist reference I have found that deals specifically with critiquing homeopathy and acupuncture. Unfortunately this idea is not explored further. Moreover, a thorough review of recent feminist journals found only one reference that dealt specifically with alternative therapies. However, there are some debates about other areas of women's health that offer interesting ways to look at unorthodox therapies. Celia Kitzinger (1993) examines psychology in the light of the feminist slogan 'the personal is political'. She argues that psychology personalises the political turning social, economic, and ecological concerns into individual psychologies. Empowerment depends on a radical split between the personal and the political fostering revolution from within at the expense of political change in the outside world. Furthermore, by solely validating women 's experiences it ignores the social and political factors that shape experience. Therefore, she utterly rejects psychology, claiming that feminism and psychology are not ethically or politically compatible. Some of the same arguments are useful when examining the use of unorthodox therapies by midwives. Morgall (1993) addresses the consequences of medical technology in the context of women's lives. The issues she addresses are relevant also to the introduction and use of unorthodox therapies for women. They include the realities of dominance, control, knowledge interests, and conflicting values. Non critical approaches to medical technology assessment aim to promote quick social adjustment, whereas a feminist approach calls for an analysis of domination as a means of preventing exploitation of one group by another. Wilkinson & Kitzinger (1993) examined alternative advice and treatment given 16 to women with breast cancer through self help books and tapes. They argue that because women often feel powerless in the hands of the medical profession, they turn to the alternative, self-help movement as it appears to offer them a measure of control and power over their lives. They believe the basic argument of self help is that we give ourselves cancer because of unhealthy attitudes, personality, or behaviour- and that we can get rid of it by developing positive thinking and /or a healthier lifestyle. They state that these tapes indulge in victim blaming of the highest order and they offer a spurious illusion of power over illness, indeed over all aspects of life. Kitzinger (1993) believes that alternative medicine's attempts to get people to take individual responsibility only reinforces such a victim-blaming approach, and ignores societal, economic factors. Schilling & Fuehrer (1993) and Simonds (1992) also examined the politics of self-help books and reached similar conclusions. They believe the books offer internal explanations for social conditions and that individual change strategies are proposed that ignore social and economic arrangements. Simonds believes self-help books only offer an illusory cure. Sethna ( 1992) analysed self-hypnosis tapes that targeted women. She calls these tapes new age neo-feminist and believes they are dangerous and noxious to women. Once again they seemingly empower women but ignore the patriarchal structures which intersect the listener's experience. Unfortunately these discussions did not explore the alternative health movement further than looking at self help books and tapes. While unorthodox therapies have been left largely unexplored by feminist writers, pregnancy, childbirth and motherhood have been widely critiqued. FEMINISM AND MIDWIFERY Feminist writers in the social sciences, and within midwifery, have explored the issues surrounding pregnancy, childbirth and motherhood. However, the most influential writings in the popular press have been written by social scientists (Kitzinger, 1988a, 1988b, 1991; Rich, 1976; Rothman, 1982, 1996). Their writings have strongly influenced the way women have viewed childbirth and motherhood, resulting in women demanding changes within the maternity system . These works all include perspectives on midwifery and midwifery practice looking at the issues of patriarchy, power. and control. 17 There is a paucity of feminist midwifery literature. That is not to say that there are no midwives writing challenging and thought provoking material. Quite the contrary, but it is not explicitly feminist. Reinharz (1992) believes that some (social policy) feminists deliberately do not mention their feminism to circumvent the prejudiced response many people have to the word . I believe the same could well be true for midwifery. McCool & McCool (1989) present a historical overview of feminism and nurse­ midwifery in the U.S.A. They suggest that while childbirth is often an exciting and joyous event, it also presents issues of power and control which have deep social and political ramifications. They urge nurse-midwives to evaluate the midwifery profession and its future within a woman-centred perspective. The reality of practising as a feminist midwife in a hospital setting has been described by Kirkham (1988). Kirkham writes from her own experience and suggests ways feminist midwives can enhance their practice and obtain support from one another. Homebirth has been studied from a feminist perspective (Bortin et al., 1994). They believe that a feminist qualitative research approach recognises the centrality of women in birth. I would add it also recognises the importance of midwives in caring for birthing women. Two New Zealand midwives have contributed to a much needed feminist critique of midwifery in New Zealand (Donley, 1986; Fleming, 1995). Fleming's pioneering feminist-critical study analysed some of the concepts on which midwifery in New Zealand has based its practice. This analysis showed how midwives and clients develop ways of co-creating the experience of childbirth within but around the all pervasive medical structures. She recommends further studies, using similar theoretical frameworks, to further document the strengths as well as the social, political and historical barriers which may constrain midwifery practice. Joan Donley is a midwife who fights tirelessly for birthing women, childbirth choices. and midwives. She is a central figure in New Zealand maternity care and has consistently and radically challenged the status quo for many years. 18 NURSING LITERATURE Nursing interest in unorthodox therapies is high. Complementary therapies appear to be the preferred term in the nursing literature. In 1993 a special edition of a large nursing magazine focused solely on complementary therapies (Nursing Times, 1993). This was in response to the growth of interest by nurses in complementary therapies which the magazine claims has "outstripped all other areas of nursing" (p.4). The nursing literature consistently argues for a research based approach to unorthodox therapies. Although there is general information sharing, the commentary articles stress the need for, and some suggest how, nurses can initiate research on unorthodox therapies (Byrne, 1992; Gates, 1994; Osbourne, 1994). All authors recognize the lack of research on the topic. Byrne stresses it is the responsibility of all nurses to examine the research that is available and to produce the data where this does not exist. She acknowledges that quantitative methodology can be used in some cases but the majority of unorthodox therapies will also require qualitative evaluation. Gates' (1994) review of the literature also leads him to conclude that there is a relative scarcity of controlled experiments related to alternative and complementary therapies. Despite the lack of empirical evidence, he does not believe nurses should reject complementary and alternative therapies. Rather, he suggests they should review the literature before taking careful and reasoned action. The integration of complementary therapies is described by Rankin-Box (1992) within orthodox nursing care as an exciting and stimulating challenge. She calls for a standardisation of training courses in complementary therapies for nursing practice, a need for accreditation, and the development of a research base. In 1988 Rankin-Box edited a book about a selection of complementary therapies that she believes had the potential for complementing or enhancing nursing care. Each chapter gives an overview of the historical background and the principles behind the selected therapy. She stresses that complementary therapies fit into the holistic approach to nursing demanding a shift in our perception of current health care. However, 19 this book does not offer any critique of the therapies. Pfeil (1994) suggests that many nurses see complementary therapies as improving the quality of life for patients, despite the lack of 'hard data'. While encouraging research into complementary therapies, he poses the question, that if it is possible to accept that pain is what a patient claims it to be, then it should be possible to accept that wellbeing is also what the patient claims it to be. Overall the nursing literature has embraced the integration of unorthodox therapies into nursing practice. There is an obligatory call for more research included in every article but the general sense one has of reading the nursing literature is that the use of unorthodox therapies will grow regardless. While authors caution nurses in aspects of accountability and safety, there does not seem to be any critical debate about the use of unorthodox therapies. The increasing demand for unorthodox therapies by consumers is challenging the bio-medical orthodoxy. Their response, while varied, is overwhelmingly self protective and disparaging. This is the orthodox bio-medical context that independent midwives often work within or alongside. From the literature it appears as if midwives and nurses have not taken the same defensive position as doctors. On the contrary, both professional groups seem to have welcomed unorthodox therapies into their practice. There is a huge amount of interest in the different modalities and although caution is advised, there is not the sense of threat one perceives on reading the bio-medical literature. MEDICAL LITERATURE The increase in interest in unorthodox medicine has fuelled reactionary responses from the medical fraternity worldwide. Medical articles discussing unorthodox therapies tend on the whole to be disparaging (Baker, 1992; Cole, 1992, 1993; McGinnis, 1991 ). McGinnis (1991, p.1788), an American doctor who addresses unorthodox therapies in relation to cancer treatment, describes them as "questionable, ineffective, fraudulent , dubious, and unproven". He states the increasing interest in unorthodox therapies is due to "an anti-establishment, anti-intellectual, anti-medical climate, with an 20 increasingly mobile, rootless population". Paradoxically, later in the same article he acknowledges that it is affluent, well educated persons who want to take care of their health, who use unorthodox therapies. He concludes that there is no documented information that any of the unorthodox therapies are helpful and much documented information on the harmful effects. This, of course, is because he places all his belief in the scientific method and no value on "emotional, anecdotal, or testimonial" reports (p. 1791 ). Orthodox medicine demands that unorthodox practitioners prove their therapies scientifically before their treatments will be accepted (B. M.A. , 1986, 1993; Cole, 1993; McGinnis, 1991 ). However, it is argued that the scientific method is not an appropriate method for proving unorthodox therapies. It is highly likely that unorthodox therapies do not fit into the scientific paradigm and will never be 'proved ' this way (Jingfeng, 1987; Patel , 1987; Tan, 1989). Jingfeng states "an overall and impartial evaluation of AM [alternative medicine] cannot avoid the theories for that system. Since the theories of AM are based principally on ancient philosophy, it is not realistic to assess and investigate by disregarding them" (p. 665). If, however, these practitioners can prove scientifically that their therapies do work, we can be sure orthodox medicine will incorporate these practices into their medicine. Regardless of whether unorthodox therapies fit the scientific paradigm, there is public demand for them and bio-medical practitioners have had to respond . Orthodox medical associations have reacted to the growing public demand for unorthodox therapies. It is interesting to see how the British Medical Association (SMA) has done an about turn regarding unorthodox therapies in the last decade. A 1986 BMA report claims bio-medical medicine's credibility and dominance in healing, as opposed to therapies which do not "base their rationale on any theory which is consistent with natural laws as we now understand them" (British Medical Association, 1986, p.1407). This report was criticised at the time as validating modern orthodox medicine while largely being "antagonistic towards and/or dismissive of the therapeutic claims of the unorthodox" (Fairfoot, 1987, p.385). However, in 1993 the BMA published another report that represents a reversal of the original stance (British Medical Association, 1993). It recommended that priority be given to research into acupuncture, chiropractic, herbalism, homeopathy, and osteopathy. It also 21 suggests that familiarisation courses of non-conventional therapies be included within the medical undergraduate curriculum. This dramatic change of position from the orthodoxy in seven years shows how, although lagging behind their patient's needs, the B. M.A. are responding to consumer pressure. Wolpe (1990) however, would describe the change as a political response to a heretical attack. Doctors who use unorthodox medicine challenge the bio-medical orthodoxy and are described by Wolpe (1990) as heretics. They threaten the orthodoxy precisely because they are of the orthodoxy. He argues that this implies a political stance and therefore cannot go unanswered by the orthodoxy. Depending on the level of threat, strategies used to suppress challenges in the past have included cooptation (acupuncturists), isolation (chiropractors) , subjugation (pharmacists) , absorption (osteopaths), or suppression (midwives) (p.922) . It is the heretics that particularly concern Cole (1992, 1993). Cole (1992, 1993) writes frequently on issues of New Zealand medical conduct and has a particular interest in the medical profession's use of unorthodox therapies. Cole is concerned that registered medical practitioners who are scientifically trained are using 'fringe methods'. He believes ethically that "a profession proud of its scientific heritage might therefore ask a doctor providing fringe therapies to cease practising as a registered medical practitioner" (p. 132). He warns that doctors who have moved away from convention , believing they are serving their patients well , are espousing concepts that are scientifically unsound and not supported by peer experience. However, there is growing evidence that patients of orthodox doctors also want to be offered the option of unorthodox therapies. Several authors have studied the use of unorthodox medicine in general practice (Himmel, Schulte, and Kochen , 1993; Murray and Sheperd, 1993). Himmel et al. surveyed both patients and doctors and concluded that while both patients and doctors were interested in complementary medicine, nearly 70% of the patients requested that it be practised by their general practitioner (gp) more frequently than at present. Murray and Sheperd questioned patients only, and found a substantial number of them used alternative 22 therapies. They also found that these patients were frequent gp attenders with higher rates of chronic disorders. Furnham and Forey (1994) compared attitudes, behaviours and beliefs of patients of conventional and complementary medicine. They found that there were definite differences between the groups' health belief systems. Although patients of unorthodox practitioners were more critical and skeptical about the efficacy of modern medicine, they were drawn to the alternative practitioners because of their health beliefs, rather than being pushed because of their dissatisfaction with conventional medicine. Recently two books by renowned medical authors have given their support to the use of some unorthodox therapies. Enkin, Keirse, Renfrew, & Neilson (1995) have systematically reviewed data in order to provide a guide to effective care in pregnancy and childbirth. In their evaluation of non­ pharmacological methods of control of pain in labour they include acupressure, acupuncture, aromatherapy, water, massage and hypnosis. While they recommend that the effectiveness of these methods still needs to be fully evaluated, they recognise that some women find them useful and therefore they are worthy of further investigation. Wagner (1994) has published the recommendations of the World Health Organisation Perinatal Study Group, which were made by consensus, in his latest thought provoking book. "During delivery, the routine administration of analgesics or anaesthetic drugs that are not specifically required to correct or prevent a complication in delivery, should be avoided"(p.158). He recommends that consideration should be given to trying other kinds of intervention before resorting to pain relief medication in labour. Suggestions are made to use therapies such as reflexology, acupuncture and acupressure, hypnosis, massage, music and water. While supporting the role of unorthodox therapies in labour and childbirth, they have not included their use in relation to pregnancy or the postpartum period. While there is indication that some unorthodox therapies are acceptable among the bio-medical orthodoxy, there can be little doubt that the medical establishment feels challenged by unorthodox practitioners both within and outside the orthodoxy. Fairfoot (1987) and Wolpe (1990) both agree that as long as the unorthodox practitioners are not numerous or powerful enough to 23 mount a serious challenge against orthodoxy, they may be allowed to continue as a boundary testing system. While unorthodox practitioners are denied the secure status of the orthodoxy, the orthodox practitioner's position is not seriously challenged. SUMMARY Unorthodox therapies have become more popular and are being used increasingly by midwives. Midwives are attempting within their practices to offer women choices from both unorthodox and orthodox medicine. While midwives in New Zealand have autonomy of practice, they still work largely within the confines of the medical orthodoxy. The bio-medical orthodoxy remains critical of unorthodox therapies and is demanding that they prove themselves in scientific ways or forever remain marginalized. This marginalization of unorthodox therapies perpetuates the subordination of the practitioners of these therapies. Increasing the care options available to women by introducing unorthodox therapies during pregnancy and childbirth appears to be a positive experience for both midwives and the women they care for. However, the use of unorthodox therapies generally, let alone by midwives, has not been adequately critiqued from a feminist perspective. Our failure to examine the use of unorthodox therapies in this way could lead us to replicate some of the power and control issues in the existing bio-medical system. Feminism can provide midwives with the framework to investigate the subordination of women, midwifery and midwifery care within the context of our society and particularly within the confines of our medically controlled and patriarchal health system. 24 CHAPTER THREE METHODOLOGY AND METHOD The use of unorthodox therapies by five midwives has been researched using feminist case studies. This chapter discusses the methodology, method and data analysis used in this research. Harding (1987) defines methodology as a theory, or analysis, of how research does and should proceed, and method as a technique for (or way of proceeding in) gathering evidence. The methodological stance of this research is introduced by briefly reviewing feminist theory and discussing the epistemological basis for this research . The case study method used in gathering the data is outlined. Finally the data analysis is reviewed. METHODOLOGY Feminist Theory Feminism has been defined as a world view that confronts systematic injustices based on gender (Millet, 1970). This white, western, middle-class view of feminism has come under increasing challenge in the last decade (Maynard , 1994; Stanley and Wise, 1983). Women from third world countries (Gimenez, 1994), women of colour (Crenshaw, 1994; Lutz, 1993), lesbians (Hoagland, 1988) and working-class women (Lillie-Bianton, Martinez, Taylor, & Robinson, 1993) are challenging feminist theory and practice that prioritises gender over other social divisions, and that represents all women as members of the same oppressed group, unified by their experience of male domination. Many feminist writers are now placing more emphasis on the differences between women, rather than the ideal of universal sisterhood. There is a more sophisticated understanding of the relationship between race, class, and gender (Doyal, 1995). As the second wave of feminism1 began, feminists developed differing theories within feminism. The four most known theories are liberal feminism, Marxist feminism, socialist feminism, and radical feminism. Today these are 1. Second wave feminism is identified as starting with the publication of The Feminine Mystique by Betty Freidan in 1963. 25 under challenge. New and complex theories are continuing to evolve. These include African-American feminism, lesbian separatist feminism, essentialist feminism, existential feminism, psychoanalytic feminism, and post modern feminism (Rosser, 1992). Despite their diversity, all feminist theories would agree that the main issue of feminism is to address injustices involving women. They see gender as a significant characteristic that interacts with other characteristics, such as race and class, to structure relationships between individuals, within groups, and within society as a whole. With the exception of liberal feminism, most feminist theories reject the neutral objective observer for a social construction of scientific knowledge (Rosser, 1992). Epistemology influences the design and methodological stance of feminist research. "An epistemology is a theory of knowledge which considers what kind of things can be known, who can be a knower, and how (through what tests) beliefs are legitimated as knowledge" (Rosser, 1992, p.536). -Second wave feminism developed its own epistemologies as a consequence of women's attempts to explain the world from the perspective of our own lives. Three feminist epistemologies appear regularly in the literature: feminist empiricism, feminist standpoint theory, and feminist post modernism (Allen & Baber, 1992; Harding, 1987; Hawkesworth, 1989). These three epistemologies provide the current basis for the ongoing, complicated debate about the nature and status of feminist knowledge and are continually evolving. However, even these authors do not regard the three feminist epistemologies as absolutely distinct. Feminist empiricism is based on positivism and follows the mainstream scientific practices of experimentation, observation, and recording. Feminist empiricists maintain that androcentrism and sexism are identifiable biases of researchers that can be eliminated by stricter application of existing methodological norms. Feminist standpoint theory reflects the view that women occupy a social location that affords us a privileged access to social phenomena. It rejects the notion of an unmediated truth, instead claiming that class, race, and gender structure a person's understanding of reality. Its expression varies from the 26 idea that women come by nature or social experience to be better equipped to know the world than men, to the idea that a social science for women must proceed from a grasp of the forms of oppression women experience. Feminist post modernism questions the claims of a single truth or reality. It is committed to plurality, tolerance of differences and regards class, race, age, family status, and sexual orientation to be as important as gender. It challenges and exposes existing beliefs and concepts that are accepted as natural. The split between liberal and post modernist feminism, and the critiques of white, middle-class feminism by women of colour and lesbians, creates new problems and opportunities for feminist theory and practice. This discussion provides an ongoing and stimulating epistemological debate in the literature amongst feminist theorists. There is recognition that there are deep divisions among feminists as to which epistemology should prevail (Harding, 1987; Hawkesworth, 1989; Jaquette,1992; Olesen, 1994; Rosser, 1992). Stanley and Wise (1993) and Olesen (1994) recognise that while we do not have to agree with other people 's positions, we do need mutual respect between different feminisms. In fact rather than have the hegemony of one form of feminism over another, they support the need for diversity. This research is based on standpoint theory. Standpoint theory was chosen because it stresses the view that builds on, and from, women's experiences in everyday life. Postmodernism was rejected because it eschews generalisations and emphasises deconstruction , which leaves it only a limited role in challenging patriarchal structures and promoting social change (Maynard,1994). As feminist empiricism follows the standards of the current norms of qualitative inquiry, it was not considered (Hawkesworth, 1989). Bunkie (1992) contends that in New Zealand many of the attempts by the women's health movement to move medicine to a more 'patient-centred' practice are made from a feminist standpoint position. However, as with the other positions, there is ongoing debate about the standpoint position amongst scholars and there are still areas of contention (Harding, 1991 ; Hekman, 1992; Maynard, 1994; Stanley & Wise, 1993). This research 27 incorporates some of the ideas from the ongoing debates amongst feminist theorists into its stance, particularly those propositioned by Stanley and Wise (1993). Standpoint theory believes that if we start off our research (our experience) from women's lives as these are understood through feminist theory, we will be more likely to arrive at less distorted and more complete knowledge claims than if we start off only from the lives of men in the dominant groups (Harding , 1990; Jaggar, 1994). However, Stanley and Wise (1993, p.228) argue that the judging of some knowledge over other knowledge as superior is ethically objectionable. They suggest some knowledge is more preferable than other knowledge in that it fits with a proponent's experience of living, being or understanding. They argue that feminist knowledge is rooted in women 's concrete and diverse practical and everyday experiences of oppression. It is situated specific and local to the conditions of its production and thus to the social location and being of its producers. Standpoint theory insists that the knower and the known are inseparable, thus challenging the Cartesian separation of self from the world and of the analytic from the personal. Stanley and Wise (1993) and Jaggar (1994) add that emotion is vital to systematic knowledge about the social world. In this research reason and emotion are not polarised. Emotion is not seen as a second class source of knowledge, and the participants are seen as feeling, experiencing 'subjects'. Knowledge production is a crucial part of power. It becomes part of a political process where some knowledge claims are seen as superordinate to others. If we accept Stanley & Wises's idea that all social knowledge is generated as a part and a product of human social experience, we must reject ideologically derived theories of knowledge as there is no way of moving outside experientially derived understanding. Feminism is a political movement for social change which addresses injustices against women (in all their differences and similarities) . Jaggar (1994) has used a very broad definition of feminism that identifies it with the various social movements whose goals are dedicated to ending the 28 subordination of women, however they conceive it [subordination]. It is within this context of feminism that my research is placed. There are specific feminist research principles that inform the study. Feminist research principles Certain principles are unique to feminist research. These principles identified by a number of authors are: viewing women's experiences as important by using them as suitable 'problems' and sources of answers; designing research for women; and placing the researcher on the same plane as the subjects (Acker, Barry, & Esseveld, 1983; Allen and Baber, 1992; Duffy & Hedin, 1988; Hall & Stevens, 1991 , Harding, 1987; Leach, 1993; Webb,1984). The first principle puts women centrally, valuing and validating their experience in its own right. It recognises that the questions asked or not asked determine our picture of the world. The questions researched are often political, in the way that they look at understanding the dominant world forces and ways to neutralise those forces. Designing research for, rather than only of, women is the second major principle. The goal of the inquiry is to provide explanations of social phenomena that woman want and need. The knowledge produced can be used by the women themselves. It benefits women. Research for women must also be emancipatory with an ultimate goal being the end of social and economic conditions that are oppressive to women. Thirdly, feminist research places the researcher in the same critical plane as the subjects. The researcher should either study a group that is similar to herself and her own place in society or a group that is in a higher socioeconomic group. She needs to be as visible as the participants by explaining her gender, race, class, and culture in the research report. Feminist researchers must be self-reflexively gender sensitive about their own perceptions, knowledge, and biases and be willing to share these with the research participants during interaction. Feminist research is women centred, grounded in actual experiences, and closely related to social change (Webb, 1994). It is characterized by 29 interaction between researcher and participant and non-hierarchical relations. The research must have the potential to help the participants as well as the researcher (Seibold, Richards, & Simon, 1994). Feminist researchers deliberately seek challenges to their own assumptions. Research which is designed for women intends to provide explanations of social and biological phenomena that women want and need. It has emancipatory potential , enabling those researched to reflect upon the social and economic conditions that are oppressive to women. It is self-reflexive, collaborative, attuned to process, orientated to social change and concerned with the empowerment of women. Rather than rely on traditional concepts, feminist researchers are using new ways to conceptualise and evaluate rigour. Reliability and Validity The criteria by which the quality and usefulness of research are judged must be their effectiveness or potential for improving women's lives. Maynard (1994) suggests rigorous research means being clear about one's theoretical assumptions, the nature of the research process, the criteria against which good knowledge can be judged and the strategies for interpretation and analysis. Hall & Stevens (1991) have suggested specific criteria by which to evaluate femin ist research. They state that feminist researchers have had few guidelines regarding reliability and validity issues because the standards used in traditional studies do not evaluate feminist research well . They draw on a number of texts to identify criteria that assist rigour in feminist research. An explanation of reliability and validity in feminist research follows. This thesis is evaluated using these criteria. The two major criteria developed by Hall and Stevens ( 1991) are Dependability and Adequacy. Dependability increases if different investigators using similar analytic procedures perceive similar meanings. This differs from reliability in the empiricist tradition as it does not decontextualize the data. Dependability can not be assessed in this instance as there are no other similar pieces of research. Adequacy is the term they use to replace reliability and validity and implies 30 that research processes and outcomes are well grounded, cogent, justifiable, relevant and meaningful. To achieve Adequacy the following criteria are identified: reflexivity, credibility, rapport, coherence, complexity, consensus, relevance, honesty and mutuality, naming and relationality. Reflexivity fosters integrative thinking, appreciation of the truth, awareness of theory as ideology, and willingness to make values explicit. This has been attempted throughout the research process. The afterword contains my self­ reflexive reporting of the whole research process. Credibility means that the research report interpretations are validated by the participants and believability is assessed by other feminist researchers. Individual case study interpretations were validated by the participants. The entire first draft of the thesis was read by two feminist scholars. Rapport is a criterion of adequacy reflecting how well participants' reality is assessed. The participants have commented on this at the end of their own case study. Coherence indicates a unity in the research account from all observations, records, responses. and conversations involved. The research is coherent. Complexity in feminist inquiry means rejecting standardisation for exceptions and including the experiences of many differently situated women. This small study does not include the experiences of many differently situated women, but does research the experiences of midwives who are practising in a 'non standardised' way. Consensus looks for the emergence of recurring themes in the data while still noting complexities. Recurring themes did emerge from the data, although the specifics of these themes were often different. Relevance directly relates to the level of critical activism in the study. This research did not directly produce change or activism in the midwives. However, all the midwives felt it had caused them to critically reflect on their practice. Honesty and mutuality mean the research must be open and mutual without hidden agendas. My assumptions and biases are made explicit at the beginning. Naming addresses women's lives in their own terms and generates concepts through words that are expressive of women's experience. The participants are able to speak for themselves in their case studies through the use of direct quotes. Connection with the reader was a goal therefore I used direct quotes to help the reader understand her own 31 behaviour and that of others. The data analysis is written in a way that is clear and accessible to clients and midwives. Finally, relationality includes collaborative working methods both with other scholars and the research participants. The themes that were generated from the data were collaborated on with the participants on two occasions. It was participatory, there was openness, reciprocity, mutual disclosure and shared risk. As this is a Master of Arts thesis I had to work alone, albeit with the support of other scholars. Feminist researchers, therefore, incorporate a critical stance into all methods (techniques for gathering evidence or data) of traditional research. Method helps the researcher find out what she wants to know. It is not necessarily attached to one's philosophical position and does not drive assumptions. However, for this research feminist case study has been chosen as the method. The methodology described, influences the way case study method in this research is used. METHOD This section describes how case study method was used in this research . Details are given of participant selection, ethical considerations, data collection, and data analysis. Case Study Yin (1984, 1993), Wilson (1989), and Reinharz (1992) have described the purposes of case studies. Yin (1993) states that case study method is appropriate when investigators desire to define topics broadly and not narrowly, cover contextual conditions and not just the phenomenon of study, and rely on multiple and not singular sources of evidence. According to Wilson (1989) case study design is useful in gaining insight into little known problems, providing background data for the planning of broader studies, developing explanations of social-psychological and social-structured processes, and offering rich descriptive anecdotes or examples to illustrate generalised statistical findings. Reinharz (1992) believes the three major purposes for feminist case study are 32 to analyse the change in a phenomenon over time, to analyse the significance of a phenomenon for future events, and to analyse the relation among parts of a phenomenon. She continues that feminist case studies usually consist of a fully developed description of a single event, person, group, organisation, or community. It is a method which vividly documents aspects of women's lives and experiences that would be lost in other methods. Midwives' experience of using unorthodox therapies has not previously been researched. Case study seemed an appropriate method because little was known about the area of research. The topic was broad and could not exclude the context in which the midwives worked. The research provided an opportunity to analyse the way midwives' use of unorthodox therapies is significant today, and to contribute a base for future study. This research is important not only for New Zealand midwives but globally for all midwives. Because New Zealand leads the world in innovative midwifery practice we have a responsibility, as we learn and change, to document our experience for the benefit of others. This research also provided rich descriptive data to illustrate the statistical findings, that are now being documented2 , on what unorthodox therapies midwives use. Descriptive multiple-case study Case studies can be single or multiple and can be exploratory, descriptive, or explanatory (Yin, 1993). This is a descriptive multiple-case study. Multiple case studies include two or more 'cases' within the same research . Five participants, rather than a single participant, were chosen for this research as I believed there could be replication of findings between the participants. Yin (1993) states that replication of findings over multiple cases and even multiple studies can be considered a very robust finding . However, Reinharz (1992a) believes case studies look for differences as well as similarities. According to her, case studies, both single and multiple, typically look for specificity, exceptions, and completeness rather than generalizations. This research, therefore, also looks for, and acknowledges, the differences between the midwives' use of unorthodox therapies. Descriptive case study was chosen from the three types of case studies, 2. The NZCOM midwifery review process is collating these figures for 1995. 33 exploratory, explanatory, and descriptive, as the most appropriate type for this research. An exploratory case study aims to define the questions, hypotheses, or feasibility of a research procedure in a subsequent study. An explanatory case study presents data that focuses on cause-effect relationships to explain which data causes which effects. A descriptive case study presents a complete description of a phenomenon within its context, with description as its main objective (Yin, 1993). Both Yin ( 1994) and Wilson ( 1989) agree that there is a need to define the unit of analysis. The design of the case study, as well as its potential theoretical significance, is heavily dominated by the way the unit of analysis is defined. The unit of analysis in this study is the experience of five proficient independent midwives who use unorthodox therapies. The midwives work both in home and hospital settings. They were interviewed over a three month period. Kenny and Grotelueschen (1984, p.38) have identified the parameters by which case studies may be identified. They are: data are qualitative; data are not manipulated ; studies focus on single cases; ambiguity in observation and report is tolerated ; multiple perspectives are solicited ; holism is advocated; humanism is encouraged ; and common and /or non-technical language is used. The major disadvantages identified with the case study method are lack of definition (Wilson, 1989; Yin, 1994), problems with generalisability (Stenhouse, 1988; Wilson, 1989), and researcher bias (Wilson , 1989). This study is well defined through participant selection, limited time frame and subject. It is acknowledged that generalizations are limited to like cases. However, other domiciliary midwives may find a focus in the report for their own ongoing critique and reflection of their practice. Researcher bias has already been addressed under feminist theory (refer p.29) . Feminist research values the subjective experience, considering it paramount to the research process. It rejects the assumption that maintaining a strict separation between researcher and research subject produces more valid, objective research. In fact, fem inist scholars point out that quantification, although linked with objectivity, has its own inherent biases and distortions (Cook & Fonow, 1986). 34 Case studies provide a method to vividly document aspects of women's lives and achievements that would be lost in other methods. They also provide the raw data for future secondary analysis and future action on behalf of women (Reinharz, 1992). Feminist case study seeks to understand the commonalities and the differences in the midwives' experiences and look specifically at the relationship between gender and power on and in midwives' practice. Participant selection Five experienced independent midwives who practised both in home and hospital settings, and who used unorthodox therapies, were asked to participate. All of the midwives were already known to me, through professional networks, although I had not worked closely with any of them . They were approached personally by me and the background to the study and the reasons for my interest were explained. They were given the opportunity to ask questions about me and the study. Questions asked were mostly about the process of the research and the end result. They were then given an information sheet to read (Appendix one) and I called them one week later to ascertain their interest in participating in the study. The first five midwives approached were keen to participate. They all thought the topic was interesting and very relevant to their practice. The study generated interest among friends of these midwives. Several of the participants also mentioned other midwives, whom they had spoken to, who had expressed an interest in being part of the study. While, of course, there is diversity amongst the participants, it is a small group and I deliberately chose participants who tended to be homogeneous and similar to myself. They all practice independent midwifery in a large city setting. I observed that all the participants were white, middle class, middle aged, able-bodied women. I did not deem sexual orientation of the participants to be relevant to this study, therefore it was not asked about, nor did I make assumptions. 35 Ethical considerations Permission for the study was sought and obtained from the Massey University Human Ethics Committee. The following ethical concerns were considered . 1. Consent. Midwives were contacted in person. Those interested in participating were given a full explanation of the study. The time involved, the nature of the study and the possible implications were discussed as fully as possible. A follow up phone call a week later indicated their willingness to participate in the study. Written consent was obtained at the first interview and the participants were made aware that they could withdraw from the study at any time. In addition verbal consent, recorded on tape, was obtained at the beginning of each interview. Transcripts of the interviews an.d draft reports were returned to the participants. 2. Confidentiality. Participants were asked for permission for interviews to be taped. The participants were aware that this permission could be rescinded at any time. Tapes were accessible only to the researcher and her supervisor. Individual tapes were returned at the completion of the research to the participants. Transcribed interviews on computer ware were stored in a locked cabinet in the researcher's home. Pseudonyms, chosen by the participants, are used in written reports and in the final thesis. 3. Reciprocity. Reinharz (1992, p.264) states" to the extent that part of the ideology of feminism is to transform the competitive and exploitative relations among women into bonds of sol idarity and mutuality, we expect assistance and reciprocated understanding to be part of the research/subject relation ." This study involves reciprocity between myself and the participants. The interviews permitted a two way exchange of information which promoted interaction between myself and the participants. All the participants thought the research was meaningful. Participants were able to remove, add, or edit any material from the data or transcripts. My thesis is based on these edited transcripts. The case study chapters consist largely of quotes from the participants that have been organized into broad themes. Participants commented on and validated their draft chapters. Conclusions reached from the data were shared with the participants. 36 Data collection Reinharz (1992) states that research methods in feminist case studies span the spectrum of literary analysis, surveys, archival research, interviewing and others. This study used semi-structured taped interviews as the method of data collection. Semi-structured refers to a research approach whereby the researcher plans to ask questions about a given topic but allows the data­ gathering conversation itself to determine how the information is obtained. Open ended questions maximise discovery and description, exploring women's views of reality. It provides nonstandardised information that allows researchers to make full use of differences among people. We hear what women have to say in their own words. I took the following list of questions with me to each interview. What do you consider unorthodox/alternative! complementary? When do you use them? Why are you using them? What is different about them? How do you decide what to use? Hospital !home difference? Where did you learn about them? Is there pressure to use them? From whom? Is there pressure from orthodox medicine? Are midwives challenging the medical orthodoxy? What support do you have, information sharing, etc. among other midwives? What have been the repercussions you have experienced as a result of using these therapies? Do you think midwives are overusing these therapies? Are they individualised therapies? Are they empowering to women? I did not ever intend to ask each and every question. Rather they provided an overview of the topics I wished to cover. Where I did ask a question, the participants indicated, by the time they spent talking about it, whether or not that it was a relevant question to their practice. Participants often led the interview in their own direction of interest about unorthodox therapies. 37 Moreover, I did not define 'unorthodox therapies' for my participants preferring instead to hear their own interpretation of it. Consequently the interviews included discussion about both unorthodox therapy and unorthodox care. I spoke to each midwife individually about the research prior to the taped interviews. Each midwife was interviewed, on tape, twice and had the opportunity to comment on the final draft of their chapter (see Appendix 2). Multiple interviews have the potential for developing trust, the opportunity to share interview transcripts with the interviewee and invite the interviewee's analysis. They are more likely to be more accurate than single interviews because of the opportunity to ask additional questions and the opportunity to get corrective feedback on previously obtained information. Four of the midwives were interviewed in their own homes and one midwife was interviewed in her rooms. The interviews took an average of one hour each with a range between 45 to 90 minutes. The midwives were encouraged to provide examples and anecdotes. Data was collected using feminist principles. I studied women with whom I already had a bond. I was learning from, not learning about, these midwives. They also had the opportunity to learn from me. Each woman 's experience was valued and validated in its own right. I interacted with the participants during the interviews, sharing my perceptions, knowledge and biases. Individual interviews were taped. I personally transcribed all the interviews and sent copies of her own transcript to each participant. DATA ANALYSIS The data was analysed throughout data collection using case study analysis. An examination of the integrated data was done using feminist theory and the concepts of gender and power. Case Study Yin (1984, p.112) presents several important strategies for analysing case studies. He states it is important initially to have a general analytic strategy, whether that is based on theoretical propositions or a basic descriptive framework. Yin suggests the researcher has a basic descriptive framework 38 for descriptive case studies. The descriptive framework that I used allowed a chapter to each participant to tell her story. Within that chapter I organised the data around general common themes that occurred across the five participants. From the basis of this general strategy, Yin suggests a choice of three effective specific strategies to be used; pattern matching, explanation-building, and time-series analysis. He warns that none of these strategies are easy to use. The specific analytic strategies that Yin suggests are all based on predicting outcomes prior to the data collection and then comparing them with the empirical data. Outcomes were not predicted in this descriptive research, therefore these specific strategies were not relevant. However, the general analytic framework organized the case studies by identifying common themes and contrasting similarities and differences as sharply as possible. Feminist theory, and in particular the concepts of gender and power, was then used to examine the integrated data. Analysis of the data involved returning transcripts of the interviews to the participant for her input. At the second interview the participant had an opportunity to make any additions, deletions, corrections, or qualifications to the first interview that they wished. All the participants expanded on what they had originally said. We also clarified and validated data from the initial interview based on the themes I had found in the initial analysis of data. I asked women to comment on how well these themes fitted their own experiences. In this way we shared our overall analysis of the first interview and came to an agreement that reflected what the participant believed had happened. Meaning therefore was constructed in negotiation with the research participants. This avoided my taking control of the participants and provided a sense of connectedness. Individual case studies were returned to the participants prior to the final draft for their validation and their comments have been added to each chapter. This provided participants with an opportunity to check that no material by which they could potentially be identified was included and a further opportunity to comment on the accuracy of my interpretations. I deliberately worked toward producing case studies that were as free as possible of my 39 analytical voice. My interpretation of the data is limited to the organisation of the midwives' direct quotes under recurring theme headings. These quotes are interwoven with my statements. I believe the unmediated voices of the midwives have the potential to dissolve differences between the reader and the speaker (Marcus, 1986). The completed thesis will also be viewed by, and discussed with, each participant as all of the midwives have expressed interest in seeing it. Their ideas of where and how the research could be most usefully used, and expanded upon, will be gathered at this point. Gender and power were the central feminist concepts that were used to examine the integrated data. The pervasive influence of gender divisions on social life is an important defining characteristic of feminist research, in relation to patriarchal power and control. The health system is a socially structured experience that reflects the gender based organisation of our society with all its related inequities. Despite the fact that midwives work from a midwifery (woman centred) model the reality is that they also work within the confines of the larger health system, which is medically controlled and patriarchal. Gender Gender is learned behaviour that meets social expectations associated with being female or male. The differences between the sexes are seen to be the source of gender differences. Within these gender differences the sexuality of a female, or male, is clearly defined. Gender divisions are sustained through a process of genderisation and within this there is hierarchy of sexuality (Coppock, 1995). However, Torres (1992) argues that gender must not be treated as an individual characteristic or difference but as a matter of social relations and power. Likewise, MacKinnon (1987) believes in the idea of gender as dominance, rather than difference and that the difference defined as sex difference only becomes important as a consequence of power. The need to continuously and reflexively attend to the significance of gender and gender asymmetry is a basic feature of feminist research. Gender is an integral part of the research process, not just something to be studied. I am a gendered being and I recognize this influences my interpretations and analysis (Cook & Fonow, 1986). Therefore it is necessary to be reflexively open and honest about the research process (Maynard , 1994). 40 Women and their experiences are the focus of my inquiry. The researcher, the participants and their clients are all women. Obviously I have a concern with generating data that comes from the perspective of women. However, the relationship of women to men also needs to be analysed so we can understand how women's experiences in a male world are structured. Stanley and Wise (1993) are of the opinion that all feminist theories minimise the complexities of actual relationships between women and men, which may, in particular times, places and situations undermine or even reverse elements of oppression and the supposed powerlessness of women. Power Standpoint theory positions women subordinate to men although the specifics of that subjugation differs. This view of power has been challenged (Jones & Guy,1992; Stanley & Wise, 1993; Torres, 1992 ). These authors view power as shifting , uneven, and context-dependent rather than inherent within categories of people. They see it as contradictory and variable. While they do not deny that power is played out and experienced in gendered-patterned ways, they also argue that simple dualisms, for example men/women, heterosexual/lesbian, don 't explain the variability of power. Power is lived out in uneven and fragmented ways between different categories of people but it is also variable within the experience of one individual. Jones & Guy ( 1992) see a conception of power which is variable, resisted, and productive, as well as dominating, as a more optimistic and empowering approach than one which divides and makes power both invariably oppressive and personal. It places power in a historical and structural context rather than a personal one. Power can be understood by looking at its operation in specific contexts but its basis in local and variable patriarchal, capitalist and colonial formations must not be forgotten. Coppock (1995, p.43) believes the concern to theorise power within the structural and institutional relations which subordinate women and the 41 development of knowledge which analyses power and its dynamic impact on the lives of women, have done much to deconstruct patriarchal and essentially masculinist paradigms. This study analyses midwives' use of unorthodox therapies by identifying and comparing themes both within a midwife's practice and between the midwives. It uses a feminist analysis which includes the concepts of power and gender. As a result of this feminist examination, I found I generated more questions than I provided answers. These questions are scattered throughout the analysis. SUMMARY This chapter has outlined the methodology, method, and data analysis on which this study is based. Bryar (1995, p. 211) states "qualitative research .. . has the potential to uncover people's real feelings about their lives, their midwifery care or, for midwives, to describe the reality of being a midwife". This study seeks to describe the reality of being a midwife using unorthodox therapies in a bio-medical orthodox system through a feminist case study method. 42 INTRODUCTION TO DATA Chapters four to eight are the stories of each of the five participants who were interviewed. Each of the participant's stories is presented in a separate chapter. I have let the participants speak for themselves with a minimal amount of commentary, although I have organized their stories into theme headings. I drew out what I interpreted as the major themes from each of the first interviews. These themes came from reading and rereading each of the participant's interviews. I then discussed these themes with the participants at the second interview. The themes were commented on, and validated by the participants at the second interview. The themes developed and subsequently changed after the second interview. At this point I compared all the participant's themes and found some similarities occurring between participants. Where