Childbirth is challenging and while there is a reliance on experts such as midwives and doctors to provide education in the rules for birth (Cheyney, 2011), informal sources of information regarding pregnancy and childbirth are still cited by many women as being more influential. These sources include magazines, the internet (both formal health education sites and chat forums), other women's birth stories and the experiences of the woman's own mother (Gibbins and Thomson, 2001; Fisher et al, 2006; Madge and O'Connor, 2006; Cheyney, 2011; Records and Wilson, 2011; Lagan et al, 2011; Martin et al, 2013). This finding prompted the exploration of online birth stories from a parenting website for this article, to investigate the purpose of sharing birth stories from the perspective of the teller, and reflect on what we can learn as professionals from such stories and storytelling activity.
In a study by Madge and O'Connor (2006), respondents reported using parenting internet sites principally as a source of support (76% of respondents). Reading other people's stories and knowing others are experiencing similar problems were cited as the most important motivations. Crucially, the parenting internet site was described as a safe space, a community of predominantly women who had a shared experience, suggesting empathy (Kozinets, 2010). This led to a high degree of trust and a space to try out their new identity as a mother with the protection of anonymity the internet offered (Madge and O'Connor, 2006). In the study by Lagan et al (2011) across five countries, respondents also reported using different internet sites as a source of support and reassurance. Information was cross-checked across sites for consistency and frequently compared with their own beliefs or those expressed by family and friends. Importantly, the information they acquired made them feel in control, informed and gave them the confidence to speak to health professionals as equals (Gibbins and Thomson 2001; Madge and O'Connor, 2006). The posting of birth stories on an internet forum is proposed here as a method used by some women to access this supportive community, while seeking reassurance about who they are in the retelling of a specific version of their birth experience.
Method
A selection of 15 consecutively posted birth stories, self-classified as ‘trauma’ birth stories, were taken from the publicly accessible ‘coffee house’ chat room of the UK-based internet parenting site Netmums (www.netmums.com) in January 2014. Netmums was chosen for its dedicated ‘birth story’ section of the community. The only motivation for women posting their stories was a prize for the best one. Also, site users come from a variety of locations, ethnicities and backgrounds, adding depth to the reported experiences. Other popular internet parenting sites only included birth stories in response to user posts. This increases the potential for the story to be tailored to the reader rather than the story reflecting what the woman feels she needs to say. Permission for use of the birth stories was granted by the Netmums administrators. Consecutive stories were sampled to reduce researcher bias and increase the validity of the findings.
All stories represent an interpretation of an event (Clandinin and Rosiek, 2007), shaped by the changing significance over time of social, cultural and institutional influences (Mishler, 2004). Thus a story performs a function by being told. One such function is the formation of a person's identity through the stories people tell themselves and others about who they are (Reissman, 2008). The Labov and Waletsky technique of narrative analysis used here attempts to expose such functions or purpose in a story, through analysis of both the structure and the themes of the story (Labov and Waletzky, 1967). The potential bias from the offer of a prize for the ‘best’ story on the Netmums site is accounted for in the analysis. Structural elements of the story reflect how the story is told in the use of adjectives, dramatic emphasis, construction of the plot and various grammatical points. These are analysed separately from the content of what is said. The content is coded and analysed thematically (Labov and Waletzky, 1967). Both elements of the analysis are then combined. In the 15 birth stories, the structural analysis revealed a ‘protest event’ within each story. This is where the direction of the story changes as each narrator reacts against the situation they have described in the first part of their story. Despite variation in the 15 storied experiences, three broad themes emerged from the detailed coding of the story contents (Reissman, 2008). Excerpts from three of the stories are presented here as an example of these emergent themes to illustrate potential different functions behind sharing birth stories on the internet site. A reflection on the potential insights midwives can obtain from such stories is explored in the discussion.
Results
Structural analysis of the 15 ‘traumatic’ birth stories revealed the presence of a ‘protest event’ embedded within each story (Labov and Waletzky, 1967). This event describes a change in power dynamic within the narrative, as the storyteller protests against the situation and takes the opportunity to re-establish control within the unfolding events. This reveals the function of telling the story as ‘identity work’. This refers to the presentation of a desired identity to the reader of the story. Creating this identity for the online audience can actively reinforce ownership of that identity in the storyteller, for example being in control in a situation that is out of the storyteller's control as seen in the second story included in this article. This activity is referred to as ‘performance’ of identity. Three contrasting protest events from the birth stories of Bridget, Francis and Andrea are presented to illustrate the performance of identity work under the themes of healing identity, maintaining control and restoring coherence. The names of individuals in the stories have been changed.
Bridget—healing identity
Bridget sets the scene of her birth story by introducing a disempowering narrative, as she experiences a lack of support and information from the midwifery team. This formulates the pivotal event of her narrative:
‘20 minutes later I started having intense contractions and at around 9.45 pm begged the midwife to take me up to labour ward so I could have some pain relief. I was told that I wasn't a priority case, and I would have to wait as there was no room for me.’
Bridget reaches out to the midwife, expecting support and reassurance for her pain and the out-of-control sensation of contractions taking over her body. From her experience, she is aware of the hospital policy that pain relief is only administered in the strict monitoring environment of the labour ward. Furthermore, Frank (2013) explores the core social expectation of institutional admission as surrendering oneself to the care of its staff. As experience is reinterpreted as symptoms, entries on the medical records become the official story of the illness, against which all other versions of the story are judged. Thus the recent cervical measurement of 2–3 cm belies the interventions reserved for active labour. The intensity of her distress is recorded by the fact that she:
‘…begged the midwife to take me to the labour ward so I could have some pain relief.’
Her personal vulnerability is acutely evident in this statement as she is dependent on the midwife for her needs to be met both physically, in the provision of pain relief, and psychologically, in the acknowledgement of her experience. The midwife is in a significant position of power as she acts as gatekeeper to the support Bridget expects from the institution. Bridget reports a lack of empathy from the midwife and an assault on her dignity, as it is formed in relation to others (Jacobson, 2007), when she denies Bridget's request and violates her unique individuality and experience:
‘I was told that I wasn't a priority case.’
As the midwife follows the institutional guidelines on admission to the labour ward only when in active labour, Bridget interprets her response as a betrayal in their contract of trust (Leach, 2005). Any option for negotiation is apparently removed by the midwife saying there is no space for her on labour ward:
‘…there was no room for me.’
This statement as remembered by Bridget, portrays a feeling of not being worthy of admittance to the place she associates with sanctuary and care, despite her expectation that her needs would be met by the institution. Bridget has been informed that it is necessary for her to fit her body to the institutional rules. Her narrative proceeds with a description of going to the toilet where her child is quickly born without warning. He is unresponsive and taken away for resuscitation by the attending medical team. The protest event and core of the narrative is revealed:
‘It was without doubt the most scary, traumatising event of my life. I was all alone, apart from the midwife (and all the other ladies in the ward, just outside the toilet), and I didn't know what was happening.’
As the health professionals focus on the immediate crisis of the unresponsive child, Bridget redirects the narrative to herself. She graphically describes being left, physically exposed and torn. She successfully pulls the listener into a stark image of her traumatic world as she stands alone, in shock and exposed in the bathroom. This image portrays her as a physical vessel that carried a baby in contrast to the nurturing image of a mother. These details are vivid and could be overwhelming for the listener. She reinforces the purpose of this narrative direction by describing this birth, as recollected, as:
‘…the most scary, traumatising event of my life. I was all alone…’
Despite the physical presence of the midwife by her side and all of the ladies of the ward outside the toilet door, Bridget feels alone. The physical presence of these people is clearly not enough, implying a lack of emotional connection or care. As birth is a social act, the denial of Bridget's transfer request and the expedited delivery of her child in an environment and context contrary to her expectations, all disrupt the attempts by Bridget to maintain the coherence of her personal narrative that birth expectations and planning promote (Beaton and Gupton, 1990).
The justification by Bridget for her affective interpretation of the birth is given as:
‘…I didn't know what was happening.’
Whether Bridget was told what was happening or not, her mental perception of abandonment is enough to isolate her in her experience. Despite the competent medical response that enables resuscitation of her child and physical repair of her body, her need for care, respect and connection, classified as external control of her environment (Green and Baston, 2003), are indexed in protest against the medical management of her birth experience.
Francis—maintaining control
In contrast to Bridget's narrative, Francis shares her attempts to maintain control of her birth experience in the face of perceived opposition from the institution. She begins her narrative with a description of her need for a calm environment and trusting relationship with her midwife to facilitate her desire for a normal birth. Francis is labouring in a birthing pool at the birth centre when the staff shift changes and her attentive midwife goes home. She does not feel comfortable with the approach of the replacement midwife, which stimulates the pivotal point of the plot, illustrated in the excerpt:
‘Another midwife examined my progress (quite violently, dare I say) only to tell me that it was not possible that I had ever been at 7 (my theory is different about this, I think daylight, fear and worry actually blocked my progress, but God only knows …) I was then sent to a standard delivery room and managed to negotiate to get some rest and food before getting on to the next step. The interventions of numerous monitoring machines did nothing to reassure me or make me comfortable and the gynaecologist was far from understanding, but I was determined to fight my corner and avoid an epidural if I could manage it and choose the position I was most comfortable in (for me, standing up at the beginning and then on all fours).’
The power dynamic in the birthing room degenerates as Francis interprets unfolding events as disempowering. The tension and sense of disregard for Francis as midwives move around her performing their tasks is described by the ‘routine’ cervical examination to measure labour progress. Firstly, she describes the examination as ‘quite violent’, creating a strong image of personal violation at the hand of the midwife. Further humiliation is experienced when her previous progress is disregarded with disbelief:
‘…tell me that it was not possible that I had ever been at 7…’
This disbelief by default questions the authenticity of Francis's connection with her previous midwife, further isolating her in her birth experience.
She is removed from the sanctuary of the pool birthing room to a standard delivery room. This symbolises a move from nurturance to intervention and surveillance, publicly implying her failure as a woman to birth naturally without the requirement of medical assistance (Fahy and Parratt, 2006). As institutional practice takes over her labour, Francis's vulnerability increases in her narrative as she describes a situation of struggle. This struggle is to allow her to hold on to control of her pre-birth expectations, defining how she wishes her birth to precede. Her increasing discomfort is shared through the imagery of numerous monitoring machines and the attendance of unsympathetic staff. The protest event in Francis's narrative serves to strengthen the theme of struggle. She tries to portray a level of active participation and control in her labour despite the move to surveillance and isolation through the disconnection with staff:
‘…I was determined to fight my corner…’
This fight reveals her bottom line of avoiding an epidural in her protest against the hijacking of her labour and to:
‘…choose the position I was most comfortable in…’
Andrea—restoring coherence
Andrea entitles her story as ‘horror birth’, setting the scene for her birth as negative and traumatic. She describes dread, horror and a detailed medical account, clearly reconstructed from later debrief, of her postpartum haemorrhage. The graphic detail of the perceived violation to her dignity and physical body is broken up by personal reflection to prevent losing the attention of her listeners. She describes her experience in a distanced yet aggressive style, focusing on the emotional distress of her partner (DP) while reconstructing events.
‘My DP had tears streaming down his face watching the both of us in this situation and everyone was too busy with their duties to explain what was occurring to him. I had two doctors at the bottom of me and one with their arm inside me to their elbow forcefully ramming in and out of me trying to stem the bleed, my DP later recited; “it was like a scene from the Saw movie.” He was totally helpless.’
Despite the acute seriousness of the situation, Andrea and her husband do not remember being informed of what was going on, describing how:
‘…everyone was too busy with their duties to explain what was occurring to him.’
Andrea and her partner were extremely vulnerable in this context as they were dependent on medical intervention for the survival of Andrea and their child. Andrea's inability to ease the suffering of her partner and his inability to respond to the needs of Andrea and their daughter divert attention from Andrea's physical humiliation at the personal violation she describes experiencing. Her description reduces her to a physical vessel, but she displaces her emotional distress through concern for her partner:
‘He was totally helpless.’
Regaining coherence of these events as she faces the threat of death, it is her partner's face rather than the severity of her experience that she claims to keep in mind, perhaps as a result of her post-event processing:
‘…tear sodden face and a look of fear on his face I never shall forget.’
Discussion
Thematic analysis of the content of the 15 stories revealed the three themes of healing identity, maintaining control and restoring coherence. The structural analysis component that identified a protest event in each story suggested a meta-theme of performing an identity of control in childbirth in the absence of an expected context of care. Within this context, the telling of these stories is an opportunity for the narrators to repair their identity, damaged by experiences that contradicted their childbirth expectations. Telling to the online community can be an opportunity to test the acceptance of their healing narrative, especially where there may be a lack of interest or understanding in the individuals’ face-to-face community (Kozinets, 2010). Sharing their story can act as a powerful self-healer, showing what the individual has survived to tell (Blanch et al, 2012).
During childbirth the woman is controlled by her body rather than in control of her body. As a consequence, the concept of control in childbirth is divided into internal and external control. Internal control refers to one's own behaviour during labour and has been found to link with antenatal expectations of control and experience of pain (Green and Baston, 2003; Ayers and Pickering, 2005). External control relates to the extent to which the woman felt cared about, as opposed to experiencing care being ‘done to’ them. This concept of caring links to perceiving staff as considerate, giving help and guidance and feeling treated with respect (Gibbins and Thomson, 2001; Green and Baston, 2003; Beck, 2004; Matthews and Callister, 2004; John and Parsons, 2006; Eliasson et al, 2008).
The purpose of the protest event structuring Bridget's narrative can be taken as an attempt to heal her identity injured by the perceived medical hijack of her labour. Telling her story to the Netmums audience reflects her attempt to reclaim her story (Mollica, 2008b). She clearly describes her dependence and consequent perception of abandonment. This is exacerbated by the imposition of institutional guidelines by the midwife in opposition to Bridget's expectation of external control of the birth environment through the provision of support and care. By sharing her story, she transfers some of the suffering of her experience to the audience as listeners (Mollica, 2008c). As a result, the audience becomes a vehicle for her emotional release from the traumatic birth experience (Mollica, 2008b). For practitioners, it provides a unique insight into the sensitivity of birthing women to the power dynamic in the woman–midwife relationship, and emphasises the importance of practising woman-centred care and communication. In the very unusual birth circumstances of Bridget, perhaps postnatal debriefing with a midwife would allow understanding of what happened and why, from both Bridget's and the staff perspectives. This could be a valuable experience for both parties.
Francis's protest functions to maintain her identity as a birthing woman, rather than a passive patient, by maintaining her bottom line of not having an epidural and birthing in the position she wants. Despite her inability to exert control over the external environment of her labour, she clearly positions herself as maintaining internal control of her behaviour. This is through the battle between her expectations of the birth and the institutional model of birth as she experienced it. By describing this internal control in telling the story of the birth, she positions herself as uncompromising in the face of medical control of her labour, offering her experience as an example to other women. The importance of birth position and pain relief decisions in Francis's perception of control highlight to practitioners the importance of discussing birth expectations or the birth plan with the woman and working together to achieve them. Emphasis on antenatal birth planning can lead to expectations that are perhaps not fully met in the unpredictable arena of birth. Planning in consultation with the midwife may be a way to overcome this risk.
Andrea shares a physically and psychologically disempowering narrative, through the horror of what she experienced and criticism of the lack of emotional support given to her partner. The protest event in her story signifies a resistance narrative. This is where the medical world is seen as a source of hope, but the treatment was so unpleasant that it is not possible for her to show gratitude due to the horror of what was experienced. This sense of suffering over which the narrator has no control is described as ‘without meaning’ by Frank (2013). By focusing on the helplessness and distress of her partner, Andrea regains internal control by illustrating the inter-connectedness of her and her husband, and embodying the ethic of care (Tronto, 1993). She suffers on her husband's behalf. The just suffering of her partner thus takes on meaning as she bears witness and gives his voiceless experience a voice. Thus despite technologically advanced care, the missing relational (or caring) element is given priority in Andrea's narrative as a way for her to create coherence and re-establish an element of control from the psychological and physical assault that she experienced (Mollica, 2008a). The vulnerability of women in labour, especially when medically complicated, is often a very new experience for an otherwise healthy section of the population. Thus there needs to be increased awareness, and extra care taken, by the attending professionals as some actions or explanations may result in misunderstandings.
Analysis and interpretation of this selection of birth stories reveal the subtle but fundamental work achieved through the storytelling for both the teller and the listener. While an important psychological healing activity is potentially achieved by the teller, guidance and support are offered to the listener as different techniques of maintaining control are shared. Trauma stories are challenging to present as the professional is often portrayed negatively and not accurately. In this format there is no opportunity for these attending professionals to give their explanation of the situation. However, this exercise is not to judge staff, but to share a lesson in the potential perception of some women to their experience when they feel out of control and not accurately informed about events, and their sensitivity to the power dynamic in the birthing room.
For practitioners, valuable insight is gained into birthing women's need to retain a level of internal and external control during their birthing experience.
Conclusion
This analysis of trauma birth stories, posted on the Netmums site, uncovers an important potential space for women to try out their healing narratives. This forum can allow narrators to maintain their identity as independent women who had expectations of control in childbirth. The narration of their birth experiences highlights the performance of control in the absence of an expected context of external control or care. This process can impact both self esteem and perception of human worth.
The three stories presented in this article give three practice points for reflection: