thru the pinard Podcast
a conversational podcast with @Academic_Liz with midwives & other birth professionals about their studies/ research & how it's changing our practice globally - email thruthepinard@gmail.com
thru the pinard Podcast
Ep 100 Anna Madeley on No Is a Complete Sentence: Birth Choices Beyond Guidelines
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Ep 100 (http://ibit.ly/Re5V) Anna Madeley on No Is a Complete Sentence: Birth Choices Beyond Guidelines
@PhDMidwives #research #midwifery #education #reproductiveidentity #withholdingconsent #nonnormativecare @UniNorthants
research link - t.ly/ibBZ0
What drives women to make birth choices outside standard guidelines? Anna Madeley's pioneering research reveals it's not defiance or ignorance—it's defense of their fundamental reproductive identity.
After experiencing a challenging first birth, Anna transformed from a construction safety consultant to a midwife with passion for critical inquiry. This transformation sparked a decade-long journey culminating in groundbreaking doctoral research examining why women make what she terms "non-normative" birth choices. Moving beyond simplistic labels like "declining care" or "non-compliance," Anna's work unveils the complex identity factors driving reproductive decision-making.
The episode explores Anna's development of the QUEEN model—describing strategies women use to navigate maternity systems that threaten their core identity. From "quitting" care entirely to performing strategic compliance while maintaining internal autonomy, women employ sophisticated approaches when faced with care that doesn't align with their values.
Most revealing is Anna's Theory of Reproductive Identity Defense, demonstrating how our healthcare systems often create identity threats by disregarding women's deeply-held beliefs, experiences, and knowledge. When women resist standardised care, they're not being difficult—they're protecting essential aspects of self.
The conversation delves into striking findings, including how midwives themselves frequently make non-normative choices and how women's resistance typically begins with small refusals before escalating when autonomy isn't respected. We also discuss Anna's concurrent book publication, her charitable advocacy work, and her powerful message that "no is a complete sentence" when it comes to bodily autonomy.
Whether you're a birth professional seeking deeper understanding of client choices or someone navigating your own reproductive journey, this episode offers transformative insights into how we might create maternity systems that honour women's rights, identities, and autonomy.
Ready to rethink how we support reproductive choices? Subscribe now and join the conversation about creating maternity care that truly respects women's autonomy.
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Thank you very much for joining me, as per usual. Can you introduce yourself, please?
Speaker 2:Yes, my name is Anna Maidley.
Speaker 1:So how did you get into midwifery? Let's go back to the beginning.
Speaker 2:Wow, okay, so it feels like forever ago.
Speaker 2:So midwifery is my second career. I'd already spent 10 years qualified as a health and safety consultant, so I spent a lot of time working, but it was yeah, I mean it was okay. I worked on building sites. I specialized in sort of construction safety and particularly fire safety. So I had qualifications in that and in advanced fire safety management particularly in in construction but wider and I ended up having my first child in 2008.
Speaker 2:And, like very many other people who I'm sure can relate to this, I had a bit of a rubbish time. I mean, my pregnancy was fine, but labour was just not what I expected. Um, but labor was just not what I expected. So I clearly wasn't sort of prepared for it um, but then had um. I don't even really remember the labor, but what I do remember is is having um, having her in hospital, um, and having quite a challenging kind of time really. So I sustained an OAC, wasn't really communicated with, was on a bed, had a CTG, you know all of that sort of stuff. When I had to go for um to be uh, to theatre, I was um, put in the shower beforehand and just left bleeding. So lots of of things. I mean it was pretty miserable, pretty miserable. But you know, I turned it kind of round by during my personal period, thinking I need to do something about this because I can't let that happen to anybody else. So it wasn't by, I wouldn't call it traumatic, but it was definitely the pivotal point in in my career. Pivotal point in in my career.
Speaker 2:So I applied to midwifery um back in 2008, um, thinking, no way am I going to get in because I, you know, I was 28 at that time. I just thought, you know, didn't have a degree, didn't have anything. And I got on and and I I loved it. It was like all of a sudden, I'd found and I'm not going to use the word calling because I think that has some connotations with it but it felt like I found what I was meant to do Really odd kind of, I suppose, spiritual experience, but not with yeah. Well, it was yeah and I found something that I really loved and I engaged with and you know, I was with an amazing cohort of colleagues and I just, although I found things um challenging, I didn't find them as challenging as I thought I would do. Yeah, so, yes, so I really um engaged with it and I just found like I'd found my thing. And all the way through I mean I loved it or I love the clinical midwifery, really enjoy clinical practice and still do.
Speaker 2:But what I really found that I loved was the kind of critical thinking as part of it. It gave me a real kind of outlet to be critical around the care that was being provided. That I was seeing, and I remember very, very clearly in my second year, um, doing my first research kind of uh lecture, and I thought, oh my god, this is really interesting and everybody else in the class is sort of rolling their eyes, yes. So I thought it was almost like I'd found sort of my niche within midwifery, but anyway, so, um, so, yes, finished my degree, uh, sort of worked, worked as a rotational midwife in a couple of hospitals in that time, had another baby of course, had that baby at home and I was a high risk home birth because I'm carrying a little bit of timber at that point and because of my obstetric history.
Speaker 2:But I wasn't having my baby in a hospital because at that point I'd had, sort of during my student time, some really amazing role modeling around what safe home birth looks like. So my, my first and my 40th birth were were home births, you know. So that was really, yeah, it kind of when I, you know, when I was training that that was like I can't really explain it. It's almost like, when I look back now, my, my entire career has been predicted for me. It's really odd anyway.
Speaker 2:So, yeah, worked as a rotational midwife, came back to work after having my second baby at home which was lovely and then went into practice development and since, kind of, but did a bit of practice development and did a little bit of work around diabetes and then in 2017, decided that in the middle of my master's degree, I was going to go into education because I like teaching, you know, I like engaging with students. So in 2017, applied for my first academic role and started as a lecturer and that's kind of where sort of it's all gone on from there and that's. I've stayed in education since then but also done a few things. So I finished my master's degree back end of 2018. And then started a PhD in 2020, in the September 2020.
Speaker 2:So my first year of my PhD was during the pandemic, which was interesting. Yeah, that was, yeah, really interesting, but useful, because I found that I did my PhD full-time, so I was able to really kind of immerse myself into. It meant coming away from the profession for a little bit, but I kept my hand in by doing some associate lecturing work. Um, you know, do do some work for a couple of charities around the country. Um, shout out to them. So you've kind of kept my hand in. I want to write a book at that time as well. So that was so, that's so.
Speaker 1:Maybe we can talk about later up here with my little kind of like cheat sheets with kind of my kind of like results. Um.
Speaker 2:So your master's was that research coursework so it was um, it was a bit of both. So my I was really really lucky to be awarded a scholarship um. I applied to um, the oxford academic health science network, whilst I was clinical um to to receive some funding and support to do a master's at Oxford University, which was hilarious to me because it's quite, you know, it's got a reputation of being quite posh, yes, and never thought that I'd get it. So I did. So I did my master's in evidence based health care, which was just brilliant and I really enjoyed it.
Speaker 2:It was really challenging because I learned alongside kind of medics, international medics and other people, so you know, dentists, etc. So I was the only midwife in the room. So that's when imposter syndrome really starts to sort of gnaw at your nerves. But it was a combination of research, critical thinking, of research, critical thinking, so quant methods, qual methods, statistics, which ironically, as a qualitative researcher, my my best mark was in statistics, applied medical statistics. So but was really helpful because that has really supported me in my critical thinking around how to unpick research, that sort of thing and the application of it. I did a um, a module around research and knowledge into action, which was led by Trish Greenhowell, which is who's one of my um. Honestly just brilliant. And when she was handing out books, desperately wanted her to sign it, but I thought no, the fangirl in me would just be a bit ridiculous.
Speaker 2:I get that, I'm a fangirl of hers as well me too and remain so to to stay. And actually you know, it was that piece of work that really, um, sort of made me think about how do we actually translate knowledge in into action, and the difficulty around that and the modules, um, and models around that. So I've got really interest in that too. So, yeah, really good. And my master's thesis was my first kind of dip into what eventually came became my PhD. So I was really interested.
Speaker 2:So I ran a home birth team for a little while as a as a clinical midwife and I found that the, the women that I was supporting tended to be kind of the traditionally high risk outside of guideline women. So I got really involved in with the consultant midwife at that point around complex care planning for women because invariably women were coming to the team saying I want my baby at home and they were being told no and that then kind of sort of led to a quile of events where they would push back and lots of anxiety within the team etc. So my first piece of quality of work for my master's was around how midwives facilitate that complex care for women at home. So very, very narrow focus. But I was fascinated by the, the anxiety that that created in midwives, because I've always sat very comfortably around women's rights.
Speaker 2:You know how women make those decisions, the fact that they are legally and ethically entitled to do that, even when you know the outcomes might be poor, as long as you know, wrapped up in informed consent and all of that sort of stuff. So I've always been very clear about that for myself and I'm comfortable in my knowledge around that, so I couldn't. There was just this dissonance around why, why do other midwives find that quite challenging and it was quite. It was interesting to do that piece of work and it was the first piece of. I mean, it was only it was only a master's piece of work, but it was the first piece of work that explored those kinds of of issues so what did you find as the, what were the things that surprised you about that or the main results that came out of that?
Speaker 2:sure so. So what I found was that actually the conflict didn't come from the women. The conflict came within the profession. So it was, there was, course, was the conflict and the anxiety with the women. But the, the real problems, came because the systems didn't fit the women.
Speaker 2:And again, this is where the, the emergence of the idea came from for the PhD, because it was really clear that it was the system that that wasn't set up to be able to to support women that were making challenging choices. And, on the whole, you know, these, these women, were not making huge, you know, decisions that now I would sit back and think, wow, that that would terrify me. These were women who had a slightly raised BMI, that wanted to have their baby in a pool and couldn't in the hospital, so they were being pushed out into the community. But the anxiety that created in in my colleagues and I didn't research locally, I researched across, you know, the country where I could was being um you know I saw that that was being reciprocated everywhere. So so I found that the anxiety sat within the colleagues. It was as a result of fear of that poor outcome, uh, the fact that they generally felt that, um, or it was perceived that women clearly didn't understand the risks, because if they did, why would they? Which is, again, not not true. But what I really found was that there was this strata of midwives who took part in my, my study, that um were really facilitative, and and the way that they did that was to lean into their knowledge of women's rights and ethics and caring and compassionate, holistic, personalised care, which is what we should all be practising. So I would have loved to have done that on a bigger scale, but I couldn't because it was a master's and so that was published. Goodness, I can't even remember when it was a master's and that. So that was published. Goodness, I can't even remember when it was published. So it would have been somewhere around 2000, back end of 2018, beginning of 2019 um.
Speaker 2:And then I started toying with the idea of PhD, because I wanted to. I wanted to understand it from the perspective of women, because at that point, we've then seen a number of pieces of work being published around um. You know what? How do midwives facilitate what we traditionally wrap up as outside of guideline care although I don't call it that anymore for a variety of reasons. So work around that claire feely's brilliant work around how nhs midwives facilitate that care. Um, you've also got a huge body of work around free birthing in particular now. So again, claire, and sort of all of my colleagues around the country still looking at that because it's really important, and also the emerging work around discrete choices.
Speaker 2:So why, you know, why, are women declining induction of labour, for example? But what was really really clear in this is no one had asked the women. No one had asked the women why they're doing it, and that really frustrated me because I can't come at it, or I couldn't come at it from the perspective of we are the authoritative knowledge in all of this. Because because I knew from my research, my home birth research, that actually, you know, the women felt that they were the authoritative knowledge and they were pushing back because we took that kind of almost paternalistic stance of, well, we know best and this is how we would support it. So that's where it came from.
Speaker 1:Yeah, With your supervisors for your master's. Did you have a choice in?
Speaker 2:there.
Speaker 1:Did they continue on to your PhD?
Speaker 2:masters. Did you have a choice in there? Did they continue on to your PhD? So, no, so so my my supervisors for my masters um were assigned I think I was one of the, which was great. They were amazing um, because I was doing qualitative research and I was one of the only people doing qualitative research in the room, which I found really interesting, because most of the people that I was learning with were medics, dentists, so they were doing quite different pieces of people that I was learning with were medics, dentists, so they were doing quite different pieces of work. So I was really lucky to have some fantastic quads of researchers.
Speaker 2:I didn't. I didn't then continue to do my PhD at the same place, mostly because it was cost prohibitive and I was funding myself at that point. So you know, I would have loved, loved to, genuinely would have loved to, but I there's no way I could have done that, and there was a period of time where I had to apply for it. So, so, actually, I reached out to my, to my now supervisor, who were my supervisors at the place where I did my PhD, so the Open University in the UK and I've got, I love the OU, I've got, you know I will sing their praise for it because they just because they have an ethos around their learning and they're very aligned to the NHS and I think you know, regardless of whether that's a bit of a strange sort of analogy to make, but an Ion Bevan who developed the nhs and insted the nhs, his wife, jenny lee, was the founder of the open university. So it felt almost like fate.
Speaker 2:Yeah, really cool. Um, and I think this because their philosophy around education being transformative, around it being should be accessible to all um really sort of stood out to me. So it's one of the reasons I kind of chose the OU as one of the first places I went to to apply to do my PhD, and also because my prospective supervisors weren't midwives, so I thought that was useful for me. But also I really wanted to learn, I wanted to understand more around sociology, psychology etc. So I was really lucky that in the end I had a supervisor who's professor of medical sociology and my other supervisor was a professor of psychology. So, yeah, I was really lucky to get them on board.
Speaker 1:Did you have any conflicts with them, not understanding the midwifery context of it? No, or did you have?
Speaker 2:any kind of like discuss through that? Yeah, so not really, because. So initially I had a midwife on the panel who who kind of left and then went to another organisation. She was a midwife who'd done a PhD but she got another job and went solo. So I only had her for kind of 18 months.
Speaker 2:But it was really liberating because their perspective for me was that I'm the expert in midwifery, as a midwife, yeah, and actually their role is to support me to develop my academic knowledge and knowledge around the research process. So there was never any sort of challenge around that and that was scary at first. I have to say, liz, that was really scary at first because, like any other PhD student for my first year I'm sat there thinking I really don't know what I'm doing. I don't know what I'm doing. I don't know what I'm supposed to be doing. Um, there's no structure to this and, whilst I knew that was going to be the case, don't really know what to do. But actually I had to embrace the chaos. So I learned lots about myself through that process, um, because I thought I was always inherently kind of a bit of a free spirit. But it turns out actually I like a bit of structure and organization. When it wasn't there it was a bit panicky, but that was the making of me, I think in the PhD.
Speaker 1:It does help with a little bit of structure and guidance so you know you're on the right pathway. Because there's nothing. They were great. Let me say I'm just on there was nothing worse than putting all this work in and then you suddenly get told, no, that's wrong. It's like no yeah.
Speaker 2:And they would never do that. I have to, you know, I have to say that they always challenged me. They were, and it's always an odd relationship the supervised relationship, isn't it? Because it's not like they're not the boss, they're not, you know, in charge or whatever, but they have to take quite a strong hand. So I was very grateful for that and there were a few. There was a joke in my first year that every sort of other supervision I would cry, which is crazy. But again, it's that kind of frustration type thing and we knew we were doing well if I went a few supervisions without sobbing down team supervisors. But they were great, really good.
Speaker 1:And especially when you started it kind of like with COVID, and especially COVID was much more over there than kind of what I went through here. So I'm eternally grateful. But that also had after effects that kind of kept coming, not just in the NHS system but the education system as well. So how did you then balance that stress of trying to focus with everything else that's going around you and a family and kids?
Speaker 2:Yeah, so I was quite lucky because I took sort of three years out to do the PhD, a bit like ripping a plaster off just get it done um, it didn't really affect me, um, in terms of kind of the wider working world, because quite a lot of the stuff that I was doing, working, working on the side, um, I was able to do remotely or I would be able to go and do it, so that wasn't too much of an issue. The first year was lonely, I have say, because we didn't have necessarily that community to be able to lean into. I couldn't go to the library. That's the thing that I found most distressing is that I couldn't just go and wander around and find what I needed. But once I'd managed to be able to go onto campus to be able to do it, that was fine. I mean in terms of how I managed that with the family and kids.
Speaker 2:That that was tricky, um, but but doable. You, I just had to be super organized, like I was having to predict things and they didn't always go to plan but predict things in advance. Yeah, I don't think I can give any sort of significant insights really into that. I just I think I just had to be really organized and I approached it like a full-time job because, yeah, and I my funding. So in the end I applied to do my PhD and again was offered a scholarship for my fees, which I was eternally grateful for.
Speaker 1:But what that meant was that I could take that time out to be able to do it, balancing it is one thing, but you've said that you had a couple of sessions where you're a frustrated crier and so I am come through. So how did you then kind of keep your mental health ticking along when you weren't especially in those early days, you weren't able to have those discussions face to face. Everything was online and then. So how did you keep your mental health?
Speaker 2:yeah, great question. I mean it was. It was tricky, but I think it was about recognizing, recognizing and being kind to myself. So no one put more pressure on me than me, and I think, again, that is not uncommon with people doing PhDs on a whole, but particularly particularly midwives, I think. So it was about recognising that I couldn't do everything at once and it was. It was that. It's that old analogy of it's a marathon, it's not a sprint.
Speaker 2:So, again, what I was going to come back to is that, you know, I approached it like a full-time job and I only had three years because I was funded. So I knew at this point, at at that date, I needed to be finished, although people said to me you won't do it, because you know, most people do it over four years, and if someone tells me I can't do something well, it's like well, hold my beer. So I ended up. I did finish three years to the day. So I had to be on. It had to be really organized.
Speaker 2:But equally, I built in time. So I made sure that I was taking regular holidays and that, you know, hopefully that coincided when the kids were off school or when my husband was off and I just had to be really, really strict with myself, because it's really easy to be all subsumed with things like a PhD, isn't it? And that on your downtime you're reading stuff like that, so I would do that. But I had to be really clear with myself and strict with myself that when I am off, I am off, the laptop gets closed, the books go away, the study door gets closed, and that helps and just to keep connections with people as well.
Speaker 1:Yeah, because you never stop thinking about it. You don't. It leaves your brain. You're always chugging away on something.
Speaker 2:Yeah about it. You don't leaves your brain, you're always chugging away on something. And, yeah, and I remember actually when I got to my model. So I was about, uh, two years in and I've got a whole theory now, but part of that is a model. And I remember waking up at five in the morning with model fully formed in my head and I couldn't. I'd like people have told me that sort of stuff happens, but I never believed it and I remember thinking, oh my, oh, my god, oh, my god, that's it, that's it, that's what's going to tie it up. And I got my phone out and had to, you know, get to the long list of all these notes that I'd had, with all these things that come to me. And it's still there. I keep it on my phone because with the time, you know, 5, 18, because you know that was, I mean and still remains, quite profound for me that my brain is clearly, even when I'm sleeping, still thinking about the PhD.
Speaker 1:Oh, it's amazing what those neurons can kind of make work together. How then, did you expand your PhD from the Masters and from the women's point of view? How did you find that and what surprised you in that process and in the results?
Speaker 2:find that and what surprised you in that process and in the results? So I'd had this inkling okay, so I'd had this kind of. I'd always had conversations with people around this outside of guideline care and it seemed to be kind of quite clandestine. Whenever anyone talked about this sort of outside of guideline care or, or as it expanded, women declining care or elements of their care, it was always talked about in kind of quite hushed tones and part of my master's research findings was around how midwives would talk about the women, um, and that they, the midwives, would be framed if they supported these women, as kind of radical or, um, almost maverick. But also women were wrapped up in those definitions as well. They were those women, they were the difficult women, they were the women that you know what, they were non-conforming and that sort of rubbed me up the wrong way because I hate it, I can't bear it.
Speaker 2:I can't bear it because and you see it, with medicines don't? You don't take the medicine, so they're non-compliant. It drives me nuts and I just thought how this can't be clandestine, it can't be an underground phenomenon, because we've already got this sort of swell of research around individual phenomenon and people are talking about it. What can we do to? You know, encourage women to book on time, or, you know, take their bloods or whatever? Um, so I I wrote a research proposal looking at um. It initially started as as kind of a I wanted to do mixed methods because I wanted to understand the numbers but realized that was too much. Um, I, I had this inkling that there were lots and lots of women making these decisions, but we just don't carry those metrics in the uk. So we don't count the number of women who are free birthing, for example. We don't count the number of women who have said thank you, but I'm not having induction, I don't want intrapartum antibiotics, that sort of thing, and very rapidly. That would have. I found out that that would have been too big, so I just went down the route of okay, well, let's explore why and how women are making those decisions. Because, again, I had sort of hunches that the reason were because, you know, they'd had a poor experience or because they were on social media and to some extent we knew that was true, but I knew it wasn't the bigger picture. Because if it were, why do we have women who are coming to us in their first pregnancy saying I want to free birth or I want to, you know, have maternal, quesasarean section? And it didn't matter to me what those choices were, whether it was less or more, I just wanted to understand how and why. So the first thing I had to do was come up with a definition of what I meant, because I don't like the phrase outside of guideline care, because it positions guidelines again as and we know, don't we, that actually guidelines, um, often are not evidence-based. You know, it's based on consensus and opinion, um. So this is why I moved towards my definition of what we call non-normative care, and normative being the sociologically normative. So it's what we expect, it's what you know, it's the median, it's what most people do, and split that down into the three areas. So we have the.
Speaker 2:I talk about the kind of the outside of guideline care, as it is defined as being kind of care that is requested that wouldn't be normally recommended. These might be your VBACs at home, or, you know, raise BMI in the pool or whatever. Then you've got this category around women being offered something like an intervention, so routinely offered, so something in our NICE guidelines. That is, you know, offer women bloods at booking to do X, y, z, offer women scans. So it's those women that say thank you, no, thank you, I don't want that because that throws us into oh well, what do we do? They're the non-compliant, the non-conformist. So that's our traditionally what we call declining care, although again, I don't call it that because they're not declining care, they're withholding consent to an offered intervention. So I'm doing a piece of work around that.
Speaker 2:And then you've got this other sort of smaller category around women that are making decisions that you know there's. It doesn't necessarily throw people into a tiz, but it's. It's sort of socially non-normative. So these are the women who might eat their placentas, for example. Yeah, these are women who might do vaginal seeding. You know, it's a bit. Whatever it is, they do lotus, lotus birthing, that sort of thing. So that is how I define non-normative care or non-normative choices, and I have noticed that that phrase has started cropping up in people's vocab, which is really lovely, really, yeah and I try not to show my excitement when I see it can't help that, um, so, yeah, so non-normative care and developed this kind of um piece of work where I wanted to explore the social processes around that and understand how and why women make those decisions, so that it would then inform can we predict these behaviors? What can we do to make it safe? Um, and write into guidelines?
Speaker 2:This was the point that I knew that this wasn't underground, because I went out to advert or for participants on social media and I pressed the send button and put it out to advert on the Thursday evening and when I came into the office on the Friday morning, I had 90 emails waiting for me for women who wanted to tell me their story. And it was, and they kept coming, which was really wonderful. But equally, there's no way I could have, you know, been the custodian of all these women's narratives, because I was doing grounded theory and traditionally have quite a small sample size. So and their, their stories varied. I mean it was fascinating.
Speaker 2:There were lots and lots of different types of prospective participants who were doing all the you know all the things that we expect, the feedbacks home, all of that sort of stuff but also women that were saying all I wanted was to not be tested, um, blood tests. You know, all I wanted was to. I didn't want to be booked until 16 weeks for whatever reason, um, and then they told me about the behaviors and that they were subjected to. So that was quite difficult to hear, actually so how did you keep your emotions then?
Speaker 1:because if you're hearing these distressful experiences, knowing that you had a distressful experience as well, yeah, how did you keep that on?
Speaker 2:even par it was, it was more difficult for me hearing it as a midwife than as somebody who'd experienced that care and I think because I had sort of put away all of my because I've I advocated for myself in my, you know, my second birth and that was quite healing for me, um, and and obviously channeled that into my midwifery practice as well. But hearing some of the stories that they were telling me and knowing that I was part of that system, I found profoundly disturbing. And I remember interviewing one particular participant who told me their story of how they had been. They just didn't want a forceps birth because they'd had a really traumatic forceps birth before and they had gone through this process of negotiation with their care providers. They'd gone through this process of what they felt was, you know, really robust personalized care and care planning and then, when they came to their birth and labour, the person that they came into contact with completely disregarded everything, made some really disgraceful statements around their ability to parent based on the choices that they were making, and she yeah, I mean it was hard to hear and also how this person had sort of held them down and they talked about how it was their worst nightmare coming and she drew analogies with sexual assault and I finished that.
Speaker 2:I couldn't transcribe it, I couldn't come back to that for two weeks. I had to walk away from it and I remember that was the first time that I ever called my supervisor and I can't sit with that, you know. And, interestingly, when I was writing up, I found myself drawing on her data continuously, to, to, to evidence some of the theory, and I had to reflect on the fact that that wasn't appropriate. But I was doing it because I felt like I was responsible for her story. So there was lots of reflection around that and lots of kind of understanding of my reaction. But I just, you know, I just lent into my reflexive techniques as a researcher to be able to deal with that. But yeah, that was quite challenging.
Speaker 1:What were some of the ways that the women, apart from saying no and kind of like fulfilling their autonomy because they can't, yeah, what were some of the other ways that they took control?
Speaker 2:sure. So, interestingly, and that's the model. So at the point we're recording this, it hasn't been published, but there's a paper prepared and it's coming. It's coming.
Speaker 2:So, um, women, um, if you look at the actual tangible things that they do, there are a number of sort of strategies that they employ. The biggest one is quitting. So they will either not come into the service in the first place they will resist coming to us or that will be the end point of having been through the system. So they will either quit at the beginning or that is the end point. And in the middle, in between, there's this kind of interplay of strategies which involve things like negotiation, information, seeking, trying to find a middle ground.
Speaker 2:One of the most interesting ones is what I determined to be the nothing, but again it's the sociological nothing. So outwardly it looks like they're doing nothing, but actually, inwardly, what they're doing is they're performing nothing. So they might say, yes, I'm going to come to your appointments, and then they don't come, or they tell us what we want to hear. They play the game to be able to retain a degree of autonomy over their decision making. So there's lots of of strategies and that will be published as the queen model, so queen being quitting qu at the beginning um uh, so evaluating, um and negotiating uh it's. I think it's fascinating, so watch out for that paper I've got you, I've actually got your thesis yeah, because it helps us.
Speaker 2:The actual queen model, which are the strategies that women, um, yes, sort of engage with to be able to navigate the system, is is a very small part of the wider theory, so so the actual theory itself that I've come up with that demonstrates those social processes is the theory of reproductive identity, uh defense, etc. Um, and my theory posits that women make their decisions because of this reproductive identity. So this reproductive identity was first uh kind of conceptualized by athena over in america in 2020, but that was very much wrapped up in a very small period of time within someone's life. So I've reconceptualized that and applied it to this, um, or women's decision making. So women have a reproductive idea.
Speaker 2:Everyone actually I'm saying women, that actually everybody has a reproductive identity and it they, you draw in a number of uh areas to be able to develop it, either tacitly or knowingly, and so, of course, things like your history of trauma or you know childbirth experiences. But it's bigger than that. It also leans into your professional identity, sexual identity, ethnic identity, cultural identity, whether or not you have been pregnant before, your sexual experiences, you know everything around contraception, so all of this forms a reproductive identity which then goes on to inform your, your decision making when you come into a period of pregnancy and birth, and the reason women, um, and other birthing people, push back and make decisions like this is because they are either reinforcing their identity or they are expressing it or defending it, and when they come into a system that doesn't fit their reproductive identity, it's an identity threat, and that's where the queen model comes in. So they enact these strategies to be able to defend or express their reproductive identity. Um, and yeah, so it.
Speaker 2:It. Yeah, I don't know what to say about it. Really, it's, it's huge.
Speaker 1:No, that'd be a good paper to come out with. The papers are written, so what surprised you the most?
Speaker 2:what surprised me the most? Um, what surprised me the most is that it's happening more often than we expect. Yeah, I think it's that. Uh, that, uh, this reproductive identity is a critical mediator in decision making and can be applied across a number of factors. Uh, what else? What else surprised me? Um, so, that midwives featured really heavily in my sample. Even when I didn't want them to, they did. Um, so when I was theoretically sampling I, I saw that I had midwives in my sample, so purposefully went out and looked for people who weren't midwives. And then when I found someone that fitted the bill because you can do that in reconstructive is grounded theory at the end of her interview she tells me actually, by the way, I trained as a midwife, so I think that's really interesting.
Speaker 1:I mean that would be interesting as a follow-up to actually then interview the midwives. Yeah, yeah, yeah, it is the similarities and the differences then between a cohort of non-midwives. But then also, what does it say if midwives have the same experiences? Yes, within a system that they're part of so really interesting.
Speaker 2:My last participant, nelly. So let me tell you about nelly. She was midwife, um, and she was theoretically sampled because I wanted to make sure that the modes of birth et cetera were representative because I didn't just want one particular mode of birth. So Nellie had an elective cesarean section and as a midwife she found making that choice an identity threat because she worked in a system where actually she felt that, whether it was a perceptional, you know, or whether that was reality, that for her to make a decision around cesarean section and maternal cesarean section directly conflicted with midwifery philosophy, which I found really, again, really really interesting. And in sort of explaining that finding in the context of the wider literature, sarah Church's work.
Speaker 2:So Sarah Church is an academic midwife in London and very kindly examined my PhD. Her work was around identity, midwifery, identity and reproductive experiences. So I found that really interesting because it aligned very closely with that work. But I agree with you, I think that there is more work to be done, particularly as, going back to what I said at the beginning about the fact that certainly I came to my midwifery journey as a means of healing because of a poor reproductive experience, and I wonder whether there's something in that, so oh yeah, talking with students on their first day and the so many students and every single cohort has had it that there are students who come in because they've had such a horrendous experience that they want to.
Speaker 1:They want to make sure that women don't have that again in the future. But there's also some, and majority of them are fine. Majority of them have dealt with their issues and have unpacked their issues. There are some, however, that as we're talking about things more, you suddenly become unpacked and there they need to either take time away to deal with it themselves or they struggle because they can't see that they actually haven't dealt with their own and it can be very hard for them to separate themselves from the people that they're caring for and to be that objective, professional that's needed and not be coloured by their own experiences.
Speaker 2:Agree, and I think what's really interesting there's two things. There is the fact that when I go back to my research this thing around how women construct and reconstruct their reproductive identity the last part of the kind of theory is how they reflect on that journey that they've I hate that, it's a bit X-factor, isn't is how they reflect on that journey that they've I hate that it's a bit x-factor, isn't it? But reflect on that journey that they've had to then reconstruct their reproductive identity and then become activist, and that was part of it. So so my model and my theory explains that behavior. But equally, the second part of that is does that speak to how the system fails our women when they're going through experiences which they identify as traumatic In that they're having they will change their entire life and they will pursue activities that are healing, that are to resolve any traumatic issues that they've had, because surely if we had services that were in place that supported that, that wouldn't be necessary. Although, that being said, how many brilliant midwives do we have because of that?
Speaker 1:yeah, but we have a health care system and I don't think it matters which country you're in. The health care system is kind of consequentialism, ethics, it's the ends justify the means. The ends is to reduce the risks, regardless of what they are from a medical point of view. It wants patients that are compliant, that will say yes sir, no sir, basically, and not question and just do exactly because it makes life easier for all of the staff that's there. Things are smoother and they do want the factory sausage kind of factory, the staff that's there, things are a lot smoother and they do want the factory sausage kind of factory, and that's because it's easier for them to manage, it's cheaper for them to manage, they can kind of staff it, they can fund it. It's really hard to have that individualised care.
Speaker 1:It is and I think that's one of the issues when you look at a lot of the moral distress research that's for midwives and it's the same as in the military, as well with the moral distress in the military is that they're trying to do something in an environment that won't let them and they just keep feeling like they're hitting the head against a brick wall and eventually something's got to give, and most times it's not the brick wall, no, I agree and and again.
Speaker 2:I think this is why, of course, I think my work's important because I've spent so long with it. But women need to have the ability to say no, thank you or yes. You know this. We, our entire system and maternity care system in the UK is built on the foundations of personalisation and choice, and if we are unable to facilitate a choice that looks like just women withholding consent to an offer, then actually that demonstrates that personalised care isn't where it should be at the moment. And again, this is why I would advise anyone who is writing a guideline to accommodate within that guideline what happens if someone says no, because you know our staff then become like you say that that's where the moral distress happens, that's where the anxiety happens, that's where the you know the labeling of women being difficult and non-compliant comes from, because we're not able to work in a system that is facilitative of simple kind of choices, because that's how they start.
Speaker 2:That's the other thing that surprised me is that women don't make singular choices Once they get to the point of saying I'm going to birth at home without anybody there and I'm choosing kind of free birth as an example. But it could be anything If you look back at their history of these non-normative choices, they're usually sequential and start small. So if they have an experience where I don't know, they've come to their booking and they've said, actually I don't want you to take bloods for xyz. If someone starts with, well, yeah, of course, okay, that's fine, but we can revisit that, and that they're kind and personalizing that care, they're less likely, therefore, to go on and say, well, actually, I'm just not going to do. You know, I'm going to have my baby at home in the pool with, you know, bmi 46 and two babies on board and VBAC, all of that sort of stuff. So we need a fundamental shift in how we approach it and I'm hoping that my work will be able to support that.
Speaker 1:Absolutely be part of it. So looking at your book here, so you've got a book on birth. Perpetuation date is September 2023 that's right yeah so there's a little bit of concurrency happening here. Yeah, your day. So how did you manage to get a book ready and written at the same time as everything else is happening?
Speaker 2:well, it's funny, because it was never designed that way, liz.
Speaker 1:So when I?
Speaker 2:when I was um developing my research proposal for my PhD um the imposter syndrome, because we all suffer from it, don't? We said you're not going to get, they're not going to accept it. So I also put a book proposal in because I had um at the time been teaching students around safe sort of pre-hospital care and again, I don't like the phrase pre-hospital because that implies all births should be in hospital but around safe planning and of intrapartum care at home. So I put a book proposal into Elsevier, thinking, well, at least, if I don't get onto the PhD program, I'm not able to do it, then I'll have this project. And I was told at the same time, yes, we've accepted your proposal. And blah, blah. So thinking, oh, I'll have loads of time, all this downtime during a PhD, ha ha ha, I'll just go ahead and do that. So it it was.
Speaker 2:That was a challenge.
Speaker 2:I had to be really organized and I have to say that I had some absolutely brilliant collaborators, like some of the most you know, know, experts in their fields around.
Speaker 2:For example, sean Walker did something around physiological breach birth and you know, just brilliant. So it actually was quite nice having that to do, because I didn't design that book or want to design that book as an academic text, as in you know, strictly academic. It needed to be fun and engaging because it needed to be able to speak to student midwives, student paramedics, midwives you know there's lots in there about planning services for, for community birth and community care. So I wanted it to be really kind of laid back, which meant that it, although it didn't it wasn't I don't want to say it wasn't as um kind of taxing from a thinking about it perspective, but it wasn't, as it was a joy to do. It was a joy to do. It was something that I could lean into for fun, which makes me sound really sad, like I don't know, and it's a different writing style when you're writing it for non-academics.
Speaker 1:Academic writing is hard. It's a struggle to keep it short, sharp, shiny, um, and some of the terminology we use is a little bit wanky. Um, yeah, but having it so that it's open for anyone to kind of yeah, to be able to read and understand it, but then show that it's it's evidence-based practice and these are the reasons why I'm being able to explain that is a talent in itself but is sometimes that conversational talk is easier to write yeah, and I think I slip into um.
Speaker 2:I don't find that particularly easy anymore. I think once you're steep, steep like a teabag in academia, you, you know you end up writing like that. Oh, yes, I can be a bit verbose in my writing. I know that Reviewer 2 has told me that before. Yeah, so it was nice to be able to sort of tap into others to be able to support that publication. But the other thing with that as well is that there are vignettes in there from a number of people. And the other thing with that as well is that there are vignettes in there from from a number of people. So home birth, midwives, service users, you know doulas which was lovely because it I wanted it to be a real resource for for anyone. So I hope people find it useful. I've got plans for the update, the next edition. I know how I'm gonna sort of approach that, but yeah, it's um, it's really lovely to have it out there also where I've got on a slight discount at the moment have they.
Speaker 2:I would do that. I don't. I don't get royalties, I don't get lots of royalties, so I would rather people, yeah, get it into your libraries. And I tried to aim it as well so that it wasn't necessarily sort of uk specific. So you know, you know, the principles are the same. The other thing is I didn't want to lead with this is how to manage obstetric emergencies in the community, because that that is where the majority of texts are situated, and it's right, because we have to be skilled in that you know, home birth, midwifery is, um, you know, it's some something else, but I didn't want to lead with that.
Speaker 2:I wanted to lead with what should the service look like? You know, how do we plan equipment? What does equipment? You know, what should that look like as a standard yeah yeah, um.
Speaker 1:So yeah, I was very grateful for all of my contributors so earlier on you mentioned that you also kind of spent your time with some charities that you're involved in, so you kept that up throughout your PhD process as well as a little break. So what are you involved in?
Speaker 2:so I'm associate training for birth rights because, um, I really really enjoy um going out and teaching and supporting uh colleagues in the maternity sort of sector to understand women's rights and you know the practical application of that, so I'm really delighted. I don't do it as often as I'd like to, but I'm busy, busy at the moment. So I do that with birthrights and also for baby lifeline. So I do some work for baby lifeline around community emergencies in the community okay, which is quite nice because again, I get to go out and meet people and look at how services work around the country but also to support them to, you know, be the best that they can be in managing things like emergencies. So it's it's really good to work for them and and do some work with them, and I continue to do that not as often as I'd like, but that's when work takes a priority.
Speaker 1:You never get to play with what you want to do. That not as often as I'd like, but that's when work takes a priority. You never get to play with what you want to do. Um, no, it's true all the time. One of the publications that I did see that kind of put out is and I love the title of it, no, I know which one, you'll know, is a sentence yeah, yeah, so I wrote that.
Speaker 2:Because why did I write that? I wrote it because of, kind of the conversations I was having with colleagues around. Well, women need to justify their choices and what ifs and what's that. So it was a case of I just wanted to write something around the fact that if a woman says no, she says no, and it's around positioning this declining care as it's not really declining care. What women are doing is withholding consent, and what I've started talking more about withholding consent rather than declining care, because what that does, I feel, is it solidifies in clinicians minds the fact that it almost feels more comfortable.
Speaker 2:Yeah, because, and the analogy that I've used in some of my presentations is around if somebody is having a sexual encounter and someone says no, it's really clear that you stop because consent has been withdrawn. Yes, so I don't really understand maybe it's me and my naivety, but I don't really understand if, for example, a woman's having a um I don't know a vaginal examination and she says no, stop, why that isn't the same. And similarly, if, if somebody offers um, a pathway of care, and the woman says no, thank you. For me that is really simple. It's just withholding consent, which is why I wrote it. So, again, I, as anybody who knows me, I have lots of hills that I'm going to die on, and that's one of them is that you know. No is a complete sentence, and women are protected in law by saying it.
Speaker 1:I do. The title was just perfect and it was just like yes, yes. So what have you been doing since your PhD, then? What's? That's a great question. Exciting things have you been doing that you're going to have either finished or kind of building on to more things in the future?
Speaker 2:Yeah, so currently I work as a lead midwife for education at university and I manage a brilliant team of academics, so I've been very much kind of embedded in that because we've just launched our apprenticeship, so with my colleagues that, and had that validated in March. So that's been taking up quite a lot of my time. I've been writing publications, so I'm hoping that. So one of my first one has been submitted. So I'm currently waiting for peer review on that and I've got one prepared and one in preparation to send.
Speaker 2:But I suppose the biggest piece of work outside of that because of course I'm not just doing that is Dr Maria Healy and I are currently co-editing another book. So it is the next edition of Evidence and Skills for Physiological Birth for Midwives, which was Dennis Walsh's book, yep. So he has relinquished very kindly thank you, dennis um the book and said that he didn't want to do the next edition. So maria healy and I have come together to be able to do that. So again I've got some amazing contributors that are pulling together their chapters at the moment. We're looking to have that published sometime the back end of this year, beginning of next year. So watch this space and then potentially looking at some postdoc work. So always open to offers. So if anybody has any postdoctoral work, that's what we're looking for and that's it.
Speaker 1:One question I forgot to ask because we were so caught up. How did you celebrate? How did I?
Speaker 2:celebrate. How did I celebrate it? So, after my viva? Um, I had my viva one day and I started my new job the next. So I actually didn't celebrate for two weeks because I had to wait for some time off. But what did I do? I slept and I ate a decent meal. I don't think I've actually properly celebrated yet. It still doesn't feel real. Um, I'm 18 months down the line now, probably a bit more um from from when I finished um, and it just yeah, it doesn't. Yeah, it still doesn't feel quite real. I will do, I'm gonna go on holiday at some point when I get some time, and then we'll celebrate properly.
Speaker 1:When was the first time you used the term doctor?
Speaker 2:When was the first time? When did I first use it? It took a while, actually. It took a while I had some, so I've got some really good friends on a whatsapp group and a package arrived the day after my viva and they had some champagne and some glasses inscribed for me, which was really lovely. So that's the first time I properly saw it, but the first time using it in anger. Liz, is that what you're asking? No, no, yeah, um, the first time I properly used it is when I started my new job, actually the next day, and I, um, yeah, and I filled it in and it it's still. It's the imposter syndrome. I think everyone still experiences that. But do I bust it out? Occasionally? I do. Yeah, I use it on everything.
Speaker 2:Now I have to say, I don't use it because I don't work clinically, um, currently, um, so there's no issues there in terms of sort of blurring those boundaries around medical doctors, but I do use it everywhere because I think actually I've earned that. I've earned that title, I'm going to use it. And the analogy that I use was when I got married I did change from a miss to a missus. Nobody asked me for any qualifications, nobody sort of batted an eyelid when I went from mister to mister, mister to missus, to miss to missus. So why is it so problematic when I use that? Now, that is a title that I have earned, regardless of whether I'm, you know, in an epidemic space or not, title that I have earned regardless of whether I'm, you know, in an epidemic space or not. So I will use it.
Speaker 1:So eventually it will go on everything, but again that imposter syndrome plays a space, that kind of our marital status should have nothing to do well exactly, and the doctor makes it easy to kind of get away from that kind of option well, quite, it really does.
Speaker 2:I don't again it goes. It's down to that patriarchal society, isn't it? That is so more socially acceptable for me to be judged as to whether or not I happen to be married, but god forbid that a woman should have a PhD and use the title. You know it's mad yes, yes, excellent.
Speaker 1:Thank you very much for joining me you're very welcome.
Speaker 2:Thank you, liz.