Women and Birth
Volume 19, Issue 3 , Pages 65-71, September 2006

Women's stories of birth: A suitable form of research evidence?

  • Mary Carolan

      Affiliations

    • Corresponding Author InformationTel.: + 61 3 9919 2252; fax: +61 3 9919 2832.

School of Nursing and Midwifery, Victoria Institute of Health and Diversity, Victoria University, PO Box 14428, Melbourne 8001, Australia

Received 20 April 2006; received in revised form 26 June 2006; accepted 28 June 2006.

Article Outline

Summary 

In the past one to two decades, midwifery care has taken a new direction, which encompasses a valuing of women's birth experiences. This move has been contingent upon, and congruent with the adoption of ‘woman centred’ care and a renewed emphasis on normal birth. In line with these developments, women's stories and anecdotes of birth and midwives stories of experience increasingly form the basis of presentations at midwifery conferences and forums.

Overall, this philosophical realignment, which commenced in Australia in the early 1990s, has been applauded by many midwives in terms of a greater valuing of the wishes and experiences of childbearing women and as being consistent with a greater promotion of normal birth. Nonetheless, it also gives rise to several questions, regarding the suitability of this form of research evidence.

In a bid to answer some of those questions, this paper aims to evaluate the use of stories and anecdotal evidence within midwifery. First, an overview is presented of the way in which stories of pregnancy and birth appear in the literature. Secondly, the value of stories as evidence is critiqued and, finally, the ratio of story based publications, compared to traditional research methodologies, is reviewed. This review aims to address an area poorly attended in the literature and asks specifically: Are women's birth stories a suitable form of research evidence in midwifery?

Keywords: Stories, Narratives, Midwifery, Story-based research

 

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Background 

The idea for this paper has arisen from conversations over several years at various midwifery conferences. In that time, as midwifery moved towards ‘woman centered’ care, many changes to the content and format of midwifery conferences became obvious. Previously, midwifery matters had often been presented as an adjunct to nursing conferences. Although, in general, qualitative research had been well represented, there was now an inclusion of a new form of evidence—women's birth stories and experience1, 2, 3, 4, 5 and a shift towards a valuing and celebration of normal and intervention-free birth.6, 7, 8 A renewed valuing of the roles of doulas and lay midwives became apparent9, 10, 11 and complimentary therapies such as aromatherapy, yoga and traditional remedies also made an appearance around this time.12, 13, 14 Overall, there was much talk of empowering midwives to claim back their rightful territory, as the guardians and promoters of normal birth. For my colleagues and I, a series of questions formed the basis of our many discussions, including: Were stories and anecdotes a suitable form of evidence in midwifery? Would an emphasis on stories and women's experience detract from the credibility of midwifery in general? How was it possible to critique this level of evidence?

During this time conference themes also reflected some well-delineated phases including: an emphasis on separation of midwifery from nursing15, 16; a development of professional roles in midwifery16, 17, 18; an advancement of midwifery as a profession19, 20; an emphasis on normal birth;21, 22, 23 a valuing of traditional midwifery knowledge;24, 25 a development of partnerships with women26 and a valuing of women's experiences.27 The presentation of women's stories and experiences was common, for example refs. 5, 28, 29 and case studies were often used as a form of experience based evidence30, 31, 32. The stories of midwives and student midwives were increasingly presented (for example refs. 33, 34). Overall, this move suggested a considerable valuing of stories and experience as evidence and it is important to establish just how prevalent is this practice and in what context stories are used as evidence.

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The use of stories as evidence 

Recent trends have seen a proliferation in the literary presentation of stories and anecdotes of pregnancy, birth and early mothering, Generally speaking, these stories are presented in three broad categories. They are: women's birth stories which are analysed as data; midwives’/student midwives’ stories of birth related events which may be presented as case studies or analysed as data, and the verbatim presentation of women's birth stories without interpretation. In the first category, stories are interpreted to shed some light on women's experiences of pregnancy and birth. These analyses illuminate a wide range of maternal experience. For example, VandeVusse,35 used women's stories to examine the way in which women and caregivers interacted during decision making, while Simkin36, 37 examined women's memories of childbirth over a 20 year time-span. Other researchers sought to understand maternal experience and behaviour during adversity38, 39, 40 while still others have used women's stories to gain an understanding of maternal decision making.41 Stories of traumatic events around pregnancy and birth have also been examined42, 43 as have family stories of susceptibility to genetic disorder.44 In another direction, Callister,45 Coffman and Ray,46 and Lee47 sought to explore pregnancy and birth experiences for women from different cultural backgrounds.

In the second category, the stories of midwives and student midwives are presented as illustrative of particular cases and, for the most part, give rise to learning experiences. Several examples illustrate routine care, struggles or change encountered in practice.48, 49, 50 For example, Hildingsson and Haggstrom50 considered midwives’ narrated experiences of being supportive to prospective mothers during pregnancy while others discussed experience gained during the care of women with particular needs.34, 51, 52 Vague, in turn, discussed midwives’ experiences of interpreting the meaning of pain in labour. Other publications have used case studies to illustrate specific care episodes. For example, Nolan53 presented a case study of a woman's labour involving two different management styles while Noble54 considered the stories of home birth midwives with a view to informing practice. The attitudes of midwives when caring for women with special needs have also been explored55 and others have considered the stories of student midwives with a view to understanding how students experience and adjust to their professional roles.48, 56, 57 Meanwhile Kennedy et al.58 used narrative analysis to interpret stories provided by midwives, and in this way examined midwifery practice.

Stories of midwifery's history have also been voiced in a bid to encourage a valuing and solidarity within the profession.49, 59, 60 Downe,59 for instance, spoke of the importance of ‘using stories of midwifery's past, present and future to rebirth the profession’ while Leamon discussed midwifery's rich oral tradition as informing the foundations of practice. Moreover, other disciplines have also used midwife's stories as a way of exploring related issues. For example, anthropologist Davis-Floyd61 used midwives’ stories of emergency transport for childbearing women in Mexico to illustrate conflicts within domains of knowledge and power in health services in that country. In a parallel direction, sociologists Foley and Faircloth62 examined the work narratives of midwives practicing in the United States and discussed how participants evoked and worked through the discourse of medicine in order to validate their own profession.

In the third and final category, women's birth narratives are published largely verbatim, and without interpretation, but are valued for their ‘real’ feel. Examples include: Berstein,63 Cancellaro64 and Kitzinger.65 This body of literature seems to be aimed principally at childbearing women and may be used in a variety of health care settings, such as childbirth education, doctors rooms, family birth centres and antenatal clinics. Many of these publications are written by midwives and nurses and explore mystical and romantic associations of childbearing.66, 67, 68 Most concentrate on natural childbearing as a fulfilling experience for women.68, 69 Others, especially those written by birthing women, discuss disappointing birth experiences, and Wolf in her pointedly titled ‘Misconceptions: Truth, Lies, and the Unexpected on the Journey to Motherhood70 provides a telling example. Still others offer women's stories of successful vaginal birth in the face of odds, such as following caesarean section.71 Throughout, there is an emphasis on normal or natural (drug free) birth and women gaining control of their childbearing experience.

In all, women's birth and pregnancy stories and the stories of midwives and student midwives are seen to contribute significantly to the literature. However, it is important to now return to the earlier points and to address some of the issues raised, particularly, the suitability of stories as evidence.

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Are stories a suitable form of research evidence within midwifery? 

In the context of this paper, story-based research evidence refers to evidence that conforms to standards of reliability, credibility and trustworthiness, as outlined by a host of research opinion.72, 73, 74, 75, 76, 77, 78 This form of evidence is usually, though not exclusively, qualitative and Sandelowski's76 understanding of qualitative credibility is particularly relevant here. She states:

“… a qualitative study is credible when it presents such faithful descriptions or interpretations of a human experience that the people having that experience would immediately recognize it from those descriptions or interpretations as their own. A study is also credible when other people can recognize the experience ... having only read about it in a study” (p. 30)

Although the term validity is sometimes considered by qualitative researchers, as overtly positivist in orientation,72, 79 others such as Guba and Lincoln80 use the term ‘validity’, as an overarching concept, to question if the study findings sufficiently address issues of authenticity and credibility. These authors suggest that researchers need to ask:

•If they can trust themselves in acting on study applications

•If they would feel ‘sufficiently secure about these findings to construct social policy or legislation based on them’ (p.205).

A variety of measures are suggested to ensure the trustworthiness and validity of story-based research as evidence for practice. Those measures include the use of participants’ own words in study findings as likely to contribute to a faithful description.73, 81, 82 Others suggest leaving an ‘audit trail’, or pathway of analytic decisions, which can be followed by another researcher75, 77 while Appleton83 suggests enlisting the aid of an experienced colleague to verify categorisations and concepts. Still others suggest returning transcripts to participants for verification of content.73, 84

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The value of stories 

Within the literature, the value of stories is widely recognised and from a sociological viewpoint, stories are understood to play a key role in the way individuals interpret life events. Indeed, as Davies85 suggests, stories are the main way in which ‘events are interpreted, made tellable or even liveable’ (p. 343). For Gergen,86 narratives and stories inform important social functions such as ‘self-identification, self justification, self- criticism and social solidification’ (p. 249). Others, such as Bruner,87 consider that stories play a part in anchoring individuals to their culture and cultural practices. Within nursing and midwifery, a similar understanding of stories as important is noted. For example, Sandelowski88 considers that stories allow for a ‘sense of connection to other people’ (p. 26) while Wood and Giddings89 discuss nurses and midwives engaging significantly with people through stories. Similarly, Carolan90 discusses stories as ‘the principal means by which individuals make sense of their experiences’ (p. 5).

Within studies of childbearing women, a range of disciplines recognise the tendency of mothers to want to share their pregnancy and birth stories with other women. Examples include midwifery, the social sciences, psychology, nursing and women's health, to name but a few,90, 91, 92, 93, 94, 95, 96, 97. A number of maternal benefits are associated with this exchange. For example, Farley and Widman,92 suggest that women receive emotional and social support from other women and also learn practical information to assist them in their new role. Carolan90 suggests that women make sense of infant behaviour by exchanging stories of mothering experiences while Stewart97 goes so far as to equate the sharing of stories with ‘strength and survival’ for birthing women in remote areas of Northern Australia (p. 8). Trends of maternal learning through sharing stories are also reported by Savage98 and Samuels99 while Farley and Widman92 (p. 23) and Callister94 extend the debate and suggest that sharing birth stories allows women a sense of connection to other childbearing women and the ‘universal nature of birthing’. Overall, the literature suggests that stories play an important role in the validation of women's birthing experience, a finding supported by Brook and Barnes.100

From a professional point of view, birth stories are reflective of experience, and as such, can be considered a valuable means of accessing the social context and meaning of birth and mothering in women's lives. In this way, stories are useful in terms of ascertaining what is important to women. For example, Carolan,101 in her study of first mothering over 35 years, found that women negotiated the notion of ‘being older’ in a sequential fashion, and progressed through phases of age associated risk and disadvantage to a more positive view of themselves as patient and ‘settled’ parents. In possession of this knowledge, midwives and others involved in the care of these women may be in a position to offer more meaningful maternal support. Birth stories also assist health professionals by allowing them to monitor the effectiveness of care regimes. For example, VandeVusse35 suggested that ‘caregivers can … benefit by understanding women's critiques of the birth care they received, and can use this knowledge to improve women's experiences of birth and therefore their satisfaction with the process’ (p. 43), a finding supported by Thornburg.40 McHugh102 extends the debate and considers women's stories to be ‘the deep knowledge that is the essence of midwifery knowledge’ (p. 3) while a succession of authors acknowledge stories as an effective way of hearing the voices of childbearing women.45, 94, 101, 103, 104 In sum, despite concerns that my colleagues and I shared that stories might be viewed as a secondary and colloquial form of data, the literature suggests that birth stories actually offer a powerful and rich source of data and this finding can be extrapolated to midwifery research.

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Does the use of stories detract from the professional credibility of midwives? 

From the evidence, this would not appear to be the case. A search of the CINAHL database for the past 5 years (2000–2005), using ‘midwifery research’, ‘midwifery knowledge’ and ‘midwifery evidence’ as search terms uncovered a total of 2099 papers. Of the 2099 papers uncovered, 1533 related directly to midwifery knowledge and research and these fell into two broad categories: those considering the nature of midwifery knowledge and papers relating to either the conduct of research or the reporting of research studies. In the first category, in addition to discussing the nature of midwifery knowledge, there was a clear emphasis on critical thinking, (for example refs. 105, 106), evidence-based practice (for example refs. 107, 108, 109) and core competencies (for example refs. 110, 111, 112). Among the second category, quantitative studies, such as random controlled trials and surveys, dominated the field. Qualitative studies, although not as common, were also well represented. A further search within this corpus of literature for keywords story/stories; anecdotal evidence; experiences and discourses revealed a surprising dearth. The predominant emphasis within this body of literature was on traditional forms of empirical research with less than 1% of articles dedicated to stories as evidence.

It was difficult to believe that story based research was so sparse and a second search was undertaken on CINAHL, within the same time span (2000–2005), using the following keywords: pregnancy; birth and postpartum. This search uncovered a total of 39,790 papers. Within this body of literature a follow on search for keywords stories; anecdotes, experiences; narratives or discourses revealed a total of 383 papers, which were then hand searched for their employment of birth stories and narratives. At final count, a total of 123 papers were considered to satisfy the search criteria. This number was then further reduced by restricting publications to English speaking papers in midwifery journals and a small group of American journals of maternity nursing, chosen because of their focus on the childbearing women and her infant. Examples include Journal of Obstetric, Gynecologic and Neonatal Nursing (JOGNN) and The American Journal of Maternal/Child Nursing (MCN). At final count, 77 articles remained and, overall, papers fell into three categories: anecdotes and personal accounts; theoretical papers debating the use of stories and, finally, studies using narrative or story based methodologies. In the first category, anecdotes and personal experience accounted for 19 publications, most of which were short pieces, such as single page features, letters to the editor or commentaries, (for examples see refs.113, 114, 115). These papers included individual cases,53, 116 midwives’ personal experiences114, 117, 118 and particular issues, such as nuchal cord stories.119, 120 The second category, theoretical papers, explored the use of stories as evidence and debated their merit in understanding women's birth experiences, (for example see refs. 94, 102, 121). This section accounted for seven papers. In the final and largest category (51 papers), a large range of qualitative studies used women's stories and narratives around birth to access maternal and occasionally paternal experience. This broad array of studies included a range of participants numbering from as few as 4 to as many as 41, (for example refs. 38, 122, 123). Studies of midwives’ experience are also included in this group.52, 58

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Discussion 

One of the most surprising aspects of this review is the fact that so little emphasis is accorded to story based or anecdotal evidence. This is doubly surprising given the valuing of this form of evidence at conferences, within midwifery publications, particularly editorials and newsletters, and in textbooks. Of a possible 39,790 papers addressing pregnancy and birth, uncovered in this review, only a paltry 77 papers, a total of .019%, were concerned with anecdotes, stories and narratives. Although it is not immediately clear why this discordance exists, several possible explanations are posited. Firstly, a valuing of the oral tradition within midwifery may contribute to a situation of honoring this tradition at conferences and forums frequented by midwives. In this way, stories may be told, exchanged and used to illustrate events which may allow midwives a sense of connection to their profession and the universal nature of caring for childbearing women. Secondly, a dual valuing is evident in midwifery literature. On the one hand, midwives value women's stories of birth experiences and value each other's stories of specific clinical events. On the other hand, there is a clear emphasis on evidence based research and critical thinking. Although a dual valuing is found, this finding is not necessarily contradictory and there is evidence that, within midwifery, attempts are being made to balance both aspects of research, for example in textbooks, where both evidence based research and a valuing of women's experience are incorporated. A further confounding factor may present in the fact that publishing houses seem to prefer to publish more ‘scientifically’ recognizable studies and midwives may thus be deterred from publishing findings related to story-based evidence, despite understanding their inherent value. Finally, at present, midwifery is undergoing a stage of professional re-definition and it may be that, during this process of transition and endorsement of a new philosophy of care, midwives may be doing and learning and may thus have little time for writing.

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Conclusion 

In conclusion, this paper has debated the use of stories in midwifery research and has aimed to answer the following questions:

•In what way are stories used within midwifery?

•Are stories a suitable form of research evidence for midwives?

•What is the value of stories?

•Does the use of stories detract from the professional credibility of midwives?

In all, birth stories were found to be highly valued by midwives in terms of understanding women's experiences. Midwives’/student midwives’ stories were also valued but principally as an opportunity to learn from specific cases. Rather than detracting from the professional credibility of midwives, this attention to stories was found to be consistent with midwifery's oral culture and midwifery's ‘woman centred’ philosophy of care.

Moreover, a review of the literature revealed a surprising dearth of published articles which presented stories without analysis, which is contrary to earlier concerns about the prevalence and credibility of such research. Indeed, most midwifery research reports, uncovered in this review, conformed to quantitative methodologies although qualitative research was also well represented. Overall, story-based research comprised a very small proportion of the total review. This finding suggests that, contrary to earlier expectations and given the known benefits of stories, greater emphasis needs to be accorded to a valuing of women's stories as data.

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PII: S1871-5192(06)00026-6

doi:10.1016/j.wombi.2006.06.003

Women and Birth
Volume 19, Issue 3 , Pages 65-71, September 2006

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