ARTICLE IN PRESS

Midwifery (2009) 25, 637648

www.elsevier.com/locate/midw

Choice in maternity: rhetoric, reality and resistance

Rosemary Mander, MSc, PhD, RGN, SCM, MTD (Professor of Midwifery)a,,
Hanna-Leena Melender, PhD, RM (Senior Lecturer)b

a
School of Health in Social Science, University of Edinburgh, Teviot Place, Edinburgh EH8 9AG, Scotland, UK
b
Department of Nursing Science, 20014 University of Turku, Turku, Finland
Corresponding author. E-mail address: R.Mander@ed.ac.uk (R. Mander).

Received 30 July 2007; received in revised form 16 October 2007; accepted 21 October 2007

Abstract
Objective: to inform the organisation of the maternity services in Scotland, a phenomenological study was planned to
examine maternity decision making in two similarly small countries. The aim was to examine the experience of
contributing to decisions at clinical, organisational and policy-making levels. When examples were needed the
informants were asked to use their experience of place of birth decisions.
Design: a hermeneutic phenomenological approach was employed. In-depth, semi-structured conversations were used.
The eldwork extended over a 4-month period in 2005. The data were analysed using Colaizzis method.
Setting: Finland and New Zealand were chosen because the parallels in their health care and maternity care systems
would limit disparities. In one of the Finnish centres, the ndings were particularly homogeneous and exemplied many
of the issues arising in other settings. The ndings of the eldwork in this Finnish centre are the focus of this paper.
Participants: the informants were mothers, midwife managers/policy makers, midwives and other maternity care
providers. The ndings of 12 conversations, including mothers and all groups of staff, are reported here.
Findings: the background theme which emerged was trusting the system. The informants were aware of the extent to
which change is happening. One of the sub-themes contrasted the informants perceptions of their lack of strength
and courage with Finnish stereotypes. Being safe proved to be another crucial issue. The nal sub-theme was playing
the system.
Key conclusions: trust in a well-respected health-care system was necessary for the informants to be able to subvert or
resist that system. While such resistance has been documented in other disciplines, such as nursing, reference has
not been found in relation to maternity. The resistance to the system was, at the time of the eldwork, neither
co-ordinated nor collaborative.
Implications for practice: the ndings of this study carry important implications for womens and midwives input into
maternity care.
& 2007 Elsevier Ltd. All rights reserved.

Keywords Choice; Decision making; Resistance; Hermeneutic phenomenology; Power

Introduction assume control of her birth experience. This

includes exercising her right to make choices
In the UK, the childbearing woman has, since the (DoH, 1993). It has, for almost as long, been
closing years of the 20th Century, been exhorted to suggested that the reality of making those choices

0266-6138/$ - see front matter & 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.midw.2007.10.009
 ARTICLE IN PRESS
638
does not match the rhetoric (Mander, 1993;
Rothwell, 1996; Bharj, 2006).
The original aim of the research discussed here
was to nd out whether the choices and decision
making available to childbearing women in Scot-
land could be enhanced. Thus, a study of two
broadly comparable countries was planned to learn
from womens experiences. The countries involved
were Finland and New Zealand, whose similar
population to Scotland, with comparable health/
maternity care systems, reduced the likelihood of
disparities.
In one site in Finland, the participants demon-
strated a particularly high level of homogeneity in
their views about the experience of making choices
in the childbearing scenario. In this paper, the
background to and data from this site are scruti-
nised. This paper will aim to demonstrate how this
research was able to come to understand the
experience of making childbearing choices and
decisions in this setting. A more complete account
of the study is available elsewhere (Mander, 2005).
The choices and decisions which feature in
childbearing relate to different people and levels,
as well as to a multiplicity of topics. The choices
which were the focus of this study included not only
clinical decisions, but also those happening at
organisational and policy levels. Thus, the person-
nel involved in facilitating and making such choices
and decisions would include, as well as the child-
bearing woman, the clinician, the manager and the
policy maker.
Choices and decisions
By offering the childbearing woman choices and
supporting her as she exercises her choice, the
midwife empowers the woman and facilitates her
autonomous, self-determining behaviour. Thus,
through choice, the woman is regarded as being
able to assume some degree of control over her
childbearing experience. Such supportive midwif-
ery practice may be regarded as a reversal of
traditional patriarchal approaches, which manihy-
phen-qj;fest themselves when the childbearing
woman is considered a patient. Writing in New
Zealand, Davis (2003) traces these 20th Century
developments. She questions whether offering a
wide range of choices is helpful to the woman, as
she is obliged to tread a mineeld of choices making in abstract terms would produce wide-ranging
(Davis, 2003, p. 576). Davis argues that, rather
than offering such wide choice, the midwife
should assist the woman to make the choices
that facilitate a childbearing experience that the
woman considers satisfactory.
R. Mander, H.-L. Melender
A causative relationship between choice and
control is all too often assumed to exist. The
crucial study by Green and Baston (2003) was
needed to disentangle the complex association
between these two phenomena. Even though this
study focused on control during labour, the nding
of the fundamental importance of the womans
relationship with the midwife is more widely
relevant. While the childbearing women in this
study tended to be able to assume internal
control, that is of their own behaviour, their
external control over the staff was minimal.
This lack of external control is problematical. This
is because Green and Baston maintain that the
woman needs to be able to relinquish her internal
sense of being in control as and when she chooses.
These researchers state that relinquishing control in
this way is facilitated by the condent knowledge
that the woman can trust the midwife to follow her
choices through the womans indirect or external
control. Thus, a condent, trusting relationship
between the woman and the midwife is essential if
the womans choice is to become more than mere
rhetoric. It may be argued that such a relationship,
while more obvious, is by no means unique to labour,
as it underpins many aspects of maternity care. The
quality of this relationship, determining as it does
the womans autonomy, is largely dependent on the
midwifes ability to practice autonomously.
Thus, choice for the childbearing woman is likely
to be enhanced by the empowering working
environment enjoyed by the midwife. As has been
shown by research in England (Kirkham, 1999),
the womanmidwife relationship parallels the
midwifemanager relationship. So, a disempower-
ing organisational environment is likely to be
replicated in clinical interpersonal relationships
being similarly unsupportive.
For these reasons, in the recent study, the
decision was made to investigate the experience
of making choices and decisions in different
scenarios in maternity. In order to include a range
of decision making, the three levels to be
addressed were clinical, unitary/organisational
and policy-making levels.
Focus on a choice
Asking informants to discuss choice and decision
data. On the other hand, it might have been
perceived by the informants as disconcertingly vague.
So, to assist the informants to contemplate a more
tangible entity, a specic childbearing decision was
needed. Such a decision, which has already attracted
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Choice in maternity
attention in both study countries, as well as Scotland,
relates to the place of birth (Gulbransen et al., 1997;
Viisainen et al., 1998, 1999; Banks, 2000; Viisainen,
2000a b, 2001; Edwards, 2005a, b).
Unsurprisingly, place of birth has been shown to
be a topic bringing a multiplicity of strong feelings
(Longworth et al., 2001). This strength of feeling
makes the topic more suitable for purposes of
contemplating a tangible entity. This was demon-
strated by a study in England which used this
strategy to investigate the information given to the
woman to facilitate her decision making (Madi and
Crow, 2003). These researchers identied that in
many situations, the childbearing woman is denied
the information necessary for her to take advan-
tage of the choices available. Madi and Crow (2003)
attribute this sorry state to the midwifes reluc-
tance to give the woman unbiased information on
certain issues (p. 328). Crucially, one of these
issues was place of birth.
Madi and Crows study is comparable with a study
in Scotland (Edwards, 2001), which demonstrated
the womans limited ability to participate in place
of birth decisions. She further showed how the
midwife was prevented from providing genuine
support for the childbearing woman seeking to give
birth at home. A major nding proved to be the
difculty of achieving some degree of dialogue or
engagement between the woman and midwife.
Edwards considers that this difculty was attribu-
table to the differing knowledge bases employed by
each of them. She found that the midwife draws on
the dominant medical model, whereas the woman
utilises a social approach to decision making.
Despite this fundamental difference in orienta-
tion, Edwards goes on to suggest that the situation
of the woman and midwife has more in common
than is at rst apparent. This is because both seek
to function optimally in an environment imbued
with some threat to their respective autonomy.
This means that, rst, the womans autonomy is
threatened by care providers who, as Madi and
Crow showed, are not keen to provide complete
and unbiased information. Second, the midwife is
able to practice only as autonomously as the
health-care system permits. Thus, both are dis-
empowered. As a result, Edwards (2003) observes,
it is safer for women and midwives to rene their
coping and manipulative strategies, rather than
develop their autonomy skills (p. 11).
The aims of the research
Thus, through a selective review of the literature,
it emerged that the researchers (RM) original
639
concerns about choice and decision making did
not apply solely to the childbearing woman. The
midwifes freedom to make decisions autonomously
has been shown to be similarly constrained. These
factors may be interdependent. For this reason, it
became necessary to include not only the womans
but also the midwifes decision making in this study.
Due to previous research ndings, the choices
available to the midwife, or other maternity care
provider, also needed to be addressed.
Creating a suitable environment in which the
woman and midwife are able to make choices and
decisions has been shown to be crucial to the role
of the manager and policy maker (Kirkham, 1999).
For this reason, it was thought necessary to address
the making of organisational and policy decisions.
Due to factors emerging from the literature, it
was suggested that informants use place of birth as
a focus which they could use as a tangible entity
and possibly to provide examples of choices and
decisions.
The research question, in order to achieve
suitable depth, was framed in terms of the
meaning of the informants experience of making
decisions in maternity care. This setting was
to be interpreted broadly to include the full range
of the informants experiences. Thus, the three
groups decisions at clinical, organisational and
policy levels would be included, as has been shown
to pertain in the literature (Edwards, 1996/7;
Davis, 2003).
The research method
In order to access the meaning of the experience to
each of the participants in the maternity scenario,
it was decided that a qualitative research project
using a hermeneutic phenomenological approach
would be appropriate. While Paley (1997, 1998,
2005) has criticised midwives and nurses use of
phenomenology, it was felt that this philosophical
approach would facilitate a midwifery project
seeking to understand the depth and signicance
of informants experiences of making choices and
decisions. The underlying principle of phenomen-
ology, that the meaning of an experience lies not in
facts or observations but in the person observing
them, resonates powerfully closely with the mid-
wifery model (Walsh and Newburn, 2002).
Unlike other phenomenological approaches, such
as Husserlian or transcendental phenomenology,
Gadamer emphasises the acceptance of cultural
traditions. There is no attempt to disregard these
forestructures or preunderstandings, known
(quite positively) as prejudice, as they may
 ARTICLE IN PRESS
640
facilitate, rather than confound understanding.
Gadamer (1989) has referred to this crucially
fundamental role of cultural background as his-
toricism (p. 319). In their insightful exploration of
original German language texts, Fleming et al.
(2003) explain that historicism developed from the
belief that we are all part of history (p. 115). This
dooms any attempt by the researcher to detach
herself from past events to view them objectively
to failure.
The focus on the informant is further explained
by another fundamental underpinning of phenom-
enology. The researchers role is to access the
meaning of the experience to the informant by
striving to interpret and come to understand their
perception of it. This is done by accepting that
perception, to the extent of seeking to nd and
share aspects of the world which the researcher
and informant have in common. The researcher
endeavours, effectively, to put herself into the
shoes of the informant. In this way, the researcher
seeks to view the meaning of the experience
through the informants eyes. This endeavour,
known as intersubjectivity, is constantly sought
after by the researcher using phenomenology.
It is assisted by more complete insights into the
informants cultural context.
To strive for intersubjectivity, the researcher
recognises and seeks to access the informants life
world, which is how the informant senses her life.
It is very much the world of lived experience,
involving more than mere physical sensations of
sight, hearing, etc. Crucially, it incorporates the
signicance of objects; thus the focus is on the
things themselves as perceived through the pro-
cess of intuition (Heidegger, 1992).
The researcher aims to form a relationship with
the informant to develop a dialogue or interpreta-
tion of the phenomenon studied. In this way, the
researcher seeks the fusion of her horizon with
that of the informant or the text. In this context,
horizon is the range of vision, implying all visible
from one particular viewpoint (Gadamer, 1993).
With the fusion of horizons, the hermeneutic circle
closes and new understanding of the meaning of the
experience emerges.
The dynamic nature of achieving understanding is
summarised in the term play, to indicate the
backwards and forwards movement of dialogue
(Gadamer, 1989, p. 327). The dialogue is not con-
ned to the conversation or interview, but includes
the researchers ongoing relationship with the
informant and the continuing interaction with
transcripts and data. This playfulness is equiva-
lent to a constructive state of ux, as the distinc-
tion between the horizons of the researcher and
R. Mander, H.-L. Melender
the informant become unclear. The horizons even-
tually fuse as the interpretation facilitates new
understanding.
The research
Accessing suitable informants was facilitated with
the help of previously established collaborators and
the use of websites, together with a snowball
technique. A limitation of snowballing is the
uncertainty that the eld is comprehensively
covered (Renzetti and Lee, 1993; Faugier and
Sargeant, 1997). For example, the researcher was
not given the names of any Saami and, to her
knowledge, she met only one Swedish-speaking
Finn. Thus, these modes of access would not
produce a representative sample. Generalisability,
however, is not an aim of qualitative research. The
recruitment began with the Finnish collaborator
naming the rst few possible contacts. Thereafter,
recruitment continued by using a snowball techni-
que, which was largely by email.
The researchers lack of Finnish language skills
caused some anxiety. This was because it led to the
request that informants should be prepared for the
conversation to be either in English or involving an
interpreter. This was a source of concern because
the Finnish collaborators had warned that Finnish
people would be wary of revealing their limited
language skills. This might be aggravated by the
traditional stereotype of Finns not speaking unless
they have something to sayand often not even
then. Thus, the language problem could poten-
tially threaten the quality of the ndings.
The eldwork extended over a 4-month period in
2005 and involved in-depth, semi-structured, one-
to-one, face-to-face interviews in the form of
conversations. These were held in a place of the
informants choosing. For the professional, the
place of work was selected, while for the woman,
it tended to be her home. These locations carried
the advantage that the researcher became familiar
with the environments in which decisions were
taken.
Each informant was asked to recount her impres-
sions of decision making in the maternity setting. On
the basis of notes taken during this narrative,
particular meanings were probed, especially of
those issues which other informants had mentioned
in previous conversations. During the conversations,
the researcher needed to listen with all her senses.
One purpose of intense listening was to come to
understand the meaning of not only what the
informant said, but also what she left unsaid. So
the silences were as eloquent as the words.
 ARTICLE IN PRESS
Choice in maternity
With permission from informants, the conversa-
tions were tape recorded. They were transcribed in
full concurrently with the eldwork which allowed
reection and the beginning of data analysis to
proceed simultaneously. In this way, developing
themes could be identied and addressed in
subsequent conversations. In the Finnish centre
which is the focus of this paper, the duration of the
conversations varied between 30 and 120 minutes.
Crucial to the Gadamerian dialogue between the
researcher and the informant is their repeated
interaction. Fleming et al. (2003) discuss how
this continuing dynamic relationship assists the
fusion of horizons and the closure of the herme-
neutic circle. This continuing dialogue comprised
email contacts to express gratitude for time spent
and requests for further thoughts. Particularly
productive was the informants comments on the
transcript.
In any study using phenomenology, conversa-
tions, such as those with informants, underpin
the eldwork. Another conversation, to assist the
identication of her own preunderstandings or
prejudices, is the researchers conversation(s)
about the development of understanding of mean-
ing. This conversation took the form of a reective
research journal. This also provided a record of
the development of the research, as well as an
opportunity to reect on other relevant experi-
ences, such as reading and serendipitous discus-
sions with interested colleagues.
The research sites, as mentioned already, were
chosen to inform choice and decision making in
Scotland. The eldwork in New Zealand and Finland
represents cross-cultural research, with all of its
inherent challenges (Mander and Cheung, 2006).
However, the relevance of hermeneutic phenom-
enology to cross-cultural activity has been appro-
priately rmly established in a New Zealand
context (Spence, 2001). The aim of striving for
intersubjectivity in a different culture may only
have been partially achieved. There was, however,
at least one distinct advantage in adopting a cross-
cultural approach. This was in the recognition of
important aspects, among the routine or humdrum.
This aim has been articulated:
Hermeneutic phenomenological research y It
makes us thoughtfully aware of the consequen-
tial in the inconsequential, the signicant in the
taken-for-granted.
(van Manen, 1984, p. 38)
Striving to uncover the obscure and highlight the
hidden has long been recognised as achievable by
making the familiar strange (Shklovsky, 1917).
641
This strangeness was enhanced by the research-
ers experience of being in a different culture.
The data analysis began while completing the
eldwork. The initial stages of analysis were
ongoing during the transcription, which allowed
opportunities for reection on developing under-
standings, thus continuing the dialogues mentioned
already. One advantage of undertaking all the
transcribing personally was that it facilitated the
researchers immersion in the life worlds of
the informants. Analysis continued with re-reading
transcripts and re-listening to tapes. Doing this
employed all the researchers senses and differing
levels of understanding. These reective processes
were assisted by van Manens (1997) lifeworld
existentials (spatiality, corporeality, temporality
and relationality).
As with any qualitative research, the analysis of
data collected using a phenomenological approach
represents a potential mineeld. Lack of transpar-
ency of data analysis techniques features com-
monly. Partly to avoid this, a modication of
Colaizzis step-by-step procedure was selected
(1978). This technique carries the advantage
that, as well as being explicit, it carries scope
for modication to allow for specic situations.
Colaizzis procedure has, however, been criticised
for not tting well with the Gadamerian approach
(Fleming et al., 2003). Its exibility, however,
compensates.
In the present study, the modication of Colaiz-
zis procedure (1978) involved the following stages:
First, the transcribed and validated conversa-
tions were re-read while listening to the tapes,
to obtain a feeling for them.
Second, the signicant statements and phrases
were highlighted and extracted.
Third, the signicant statements were used to
formulate the informants meanings.
Fourth, these meanings were collected into
clusters of themes.
Fifth, based on the themes, a full description of
decision making in maternity was created.
Finally, the fundamental aspects of this topic
were stated.
Ethical issues
All ethical conventions were scrupulously followed
throughout this research, including anonymity and
condentiality. Any concerns about condentiality
are magnied because this research features both
unusual and sensitive areas. In reporting these
 ARTICLE IN PRESS
642
data, the names of the informants have been
changed.
The informants did not benet specically by
being involved and no payments were made.
Ethical approval was obtained from the relevant
research ethics committee and managerial agree-
ment was given.
The ethics of requesting informants to converse
in a language which is not their mother tongue was
considered. The availability of an interpreter was
mentioned in the invitation to participate. In the
event, most of the Finnish informants happily
conversed in English, although two requested an
interpreter.
Limitations
Qualitative research in general and the phenomen-
ological approach in particular does not lend itself
to generalisation. This may be a shortcoming.
However, it may be that the depth of the insights
more than compensates.
Similarly, it may not be possible to identify
one single answer to the research question. The
researcher strives to be faithful to the informant
and the meaning of the experience to her. This
faithfulness is sought despite the dynamic processes
accompanying the eldwork and data analysis.
In the present study, intersubjectivity was limited
by the researchers less-than-complete knowledge
of the cultures in which the eldwork was under-
taken. However, the researcher had spent time in
Finland and had worked there. This, together with
considerable reading, probably compensated for her
lack of Finnishness. It may be, though, that this
deciency was offset by the insights of a relative
stranger. The researchers non-Finnish background
is most obvious in her language. The Finns, however,
were keen to talk to the researcher and did so
carefully and thoughtfully.
Quality
The relevance of the quantitative researchers
commitment to validity and reliability has been
debated long and hard in the context of qualitative
studies (Spencer et al., 2003). The work of Lincoln
and Guba (1985) is widely regarded as the last word
in ensuring the quality of qualitative research.
These authors requirement for trustworthiness
and authenticity, however, has been moved for-
ward to encompass a range of additional charac-
teristics. These include credibility, conrmability,
coherence, consistency and exibility (Holloway
and Todres, 2005, p. 101).
R. Mander, H.-L. Melender
The ambiguously phrased member check is
superuous to demonstrating validity in phenom-
enological research, due to assumptions of inter-
subjective understanding (Holloway, 2005, p. 277).
This precaution, however, was undertaken in the
present study as both a form of quality control and
an early stage of data analysis.
Although transparency has become a cliche, it
is this level of honesty for which qualitative
researchers strive. Endeavouring to explain deci-
sions, processes, their implementation and their
signicance facilitates the readers comprehension
of the research. Through this high level of com-
prehension, the reader, crucially, evaluates the
researchs quality (Rolfe, 2006).
Findings
The sample in the setting addressed in this study
comprised 12 informants (see Table 1).
The ndings are presented here using a format
which endeavours to be faithful to the informants
ideas. This format comprises, rst, an overarching
background theme, which underpinned the views
of all groups on the meaning of decision making.
Similarly, this one major theme emerged as crucial
to the clusters of sub-themes to which it is inter-
related and which further expanded this meaning.
The titles of the sub-themes draw on the lifeworld
existentials commended by van Manen (1997) to
guide the researchers reection during the re-
search process. Van Manens existentials include
lived space, lived body, lived time and lived
human relation.
Background theme of being: trusting the
system
The theme trusting the system was ubiquitous.
This generally expressed trust regarding the health-
care system in particular as a Finnish institution
Table 1 The background of the informants.
Service user 4
Maternity care 6
provider
4 Midwives
2 Public health
nurses (PHNs)
Policy maker/ 2
manager (PMM)
Total 12
 ARTICLE IN PRESS
Choice in maternity
giving rise to what verged on a sense of national
pride. This trust in the health-care system
was extended, almost inevitably, to include the
maternity and child health-care clinic (in Finnish
neuvola) system. The importance of this meaning
of the system of maternity care was impressed on
the researcher by the informants:
our system, it has been here such a very, very
long time. Since the 40s. And almost every
woman who will get pregnantthey know this
whole system and they like to come here and
they have heardthey trust our system and I
dont know if its quite automatic.
(Kirsti, PHN)
Another informant, who was a mother, referred
to the maternity and child health-care system as
something which is utterly Finnish. This was
typical of the informants condence in the
maternity health-care clinic and also in the hospital
maternity units:
But in general, for example, I can choose how I
will have my babies and I can change my
mindthen its possible. But I think that in
hospitals they give somea few things and then
I can choose which of them I like. I think that
maybe I dont have my own ideas. In the way of
things, I really trust those people who work
there. I trust the people in the hospital and the
people in the neuvola.
(Susanna, user)
Susannas comments represent a widespread
view that the quality of the system is such that it
is not actually necessary for the woman to make
decisions. This limited need for the womans
decision making is comparable with Green and
Bastons (2003) twin concepts of internal and
external control:
But its natural to have this sort of person [the
midwife in childbirth] who is able to help you
when you are really doing somethingand when
you are so tired and so aloneits wonderful to
have someone you can trust. And you actually
have to have someone to trust, because other-
wise, as people know, you are in deep trouble
[laugh] if something happens and then this
person that you put your trust on tothat you
think in the same way.
(Susanna, user)
Thus, the ndings in this setting endorse the
work of Green and Baston (2003). It is clear that, if
and when necessary, the woman considers that her
decision making may safely be delegated to the
health-care provider, who at the birth represents
643
the much-trusted health-care system. In this
example, this proxy is the midwife.
Sub-theme of being: obtaining information
In the context of the overarching theme of trusting
the system, the sub-theme of being serves to guide
reection in one aspect of communality. The ease
of accessing the information which is necessary to
make what decisions are needed was observed by
the informants.
Myself I have two children and I think I have been
able to ask and get all the information that I
have needed.
(Marika, user)
The childbearing women considered themselves
highly adept at accessing a range of information.
A popular example was the internet (Stewart,
2005), which proved to be an important source
of information, although some informants were
cautious:
Now its awful that theres so much information
y you have so many magazines about babies,
and television of course. And it makes the
information so much.
(Minna, PMM)
But nowadays there is so much surng of the
internet. And theyre reading too much on the
internet.
(Jaana, midwife)
Well, many Finnish women know very much
about pregnancy and delivery. They read and
they chat on the internet as friends and so many
of them have a lot of information. Actually all of
the women that cant use that information, they
dont know how to cope with it.
(Anita, midwife)
Thus, some of the professionals were concerned
for the childbearing womans ability to cope with
an excess of information, which applied as much to
the internet as to other sources. The childbearing
women, however, recognised the limited relevance
to their decision making of some internet websites:
I am a bit suspicious of some of the material you
nd for new mothers on the web.
(Marika, user)
While the wealth of information available was
generally welcomed, the possibility of an excess of
information was regarded as a problem, especially
if it meant that the woman experienced difculty
 ARTICLE IN PRESS
644
in using the material for decision making. The
womans experience of obtaining information to
facilitate decisions was, occasionally, felt to be
problematical for other reasons. This may have
implied some criticism of the knowledge base of
some health-care providers:
I have heard a little while ago that you dont
have to feed your baby every 2 hours, but every
4 hoursyes. Its true in Finland now! [laugh]
And you dont have to give the breast every time
the baby cries and you dont have to breast feed
your baby at night when hes 8 months old.
Professionals give wrong information. I think that
nurses in clinics have poor information and poor
knowledge of breast feeding.
(Aino, user)
As often happens, a television programme, a soap
opera showing at the time of the eldwork, proved
to be an important source of information.
We have just a wonderful series on the
TVWilliam and Mary. William is an under-
taker and Mary is midwife and they are about
fortyish. Its wonderful!
(Pirkko, PMM)
The Mary character in the series was a midwife
offering a home birth service and many informants
admired both the character and concept. This
series popularity, however, did not affect the
general wariness about place of birth decision
making.
Sub-theme of time: making changes
Despite the limited impact of a soap opera on the
meaning of place of birth decisions, changes were
identied as happening due to other developments.
These changes resonate with the lifeworld existen-
tial which van Manen entitled lived time or
temporality. Reection on this aspect led to
the realisation of the increasing contribution of
the consumer to childbearing decisions, which is
regarded as such an inuential factor:
Womens better birth experiences with succes-
sive babies are seen as evidence that consumers
views do get to feed into the system, as Teija
says that these changes are due to complaints
being made.
(Teija, PHN, journal notes)
As well as the recognition of change happening
individually, certain consumer organisations were
regarded as variably responsible for the initiation
R. Mander, H.-L. Melender
of change. Among others, Active Birth (Aktiivinen
Synnytys Ry) was frequently mentioned:
What it is, is that it appears that women are
working together. Theres a website called
Active Birth. You have heard about it? And I
think that they are the group who are well
known, but its a minority group.
(Heli, midwife)
But Active Birth is quite active [laugh]. And I
havent been active in their work but I have read
their paper and some material.
(Susanna, user)
Thus, although widely known, this groups impact
was generally perceived as limited. In spite of this
and compared with the circumscribed role which
some groups are permitted in the UK (Edwards,
2005a, b), consumer organisations were perceived
as change agents in increasing womens ability to
contribute to childbearing decisions. Groups pro-
viding support for the breast-feeding mother and
more general support for the new mother were also
welcomed.
Sub-theme of a forestructure: being strong/
courageous
A sub-theme that may constitute a forestructure
as well as a guide to reection emerged in the
context of being able to make decisions which do
not accord with established attitudes and practice
prevalent in the Finnish health system. This sub-
theme relates to the perception of being strong or
courageous. Strength and courage are widely
regarded as stereotypically Finnish characteristics;
for this reason, regrets for the want of them did not
match the researchers expectations.
This sub-theme emerged consistently when in-
formants mentioned place of birth decisions, which
they had been asked to use as an example when
necessary. One childbearing woman recounted her
experience of deciding to and giving birth at home.
She explained it in terms of the home birth having
been a deliberate accident, which the researcher
understood to mean accidentally on purpose. This
was a decision which she narrated just as the
researcher was leaving, hence the record in her
reective journal:
Afterwards people she told said she was brave.
(Aino, user journal notes)
This woman had earlier spoken about the need
for women to demonstrate great strength in
order to make certain difcult decisions that may
 ARTICLE IN PRESS
Choice in maternity
differ from what has been recommended by the
professionals:
I think that if the woman doesnt know very
much about breast feeding, they do just like
they are told in the hospital. They dont have
any information to make a decision, but [even] if
they have information, they [still] have to be
very strong to make decisions.
(Aino, user)
One mother gave a particular impression of
being supremely strong and would be described in
Scotland as feisty and in Finland as sisukas.
During this conversation, she talked of her contact
with and impressions of home birth decision
making:
One of my friends from work had a birth at home
last week and I think it was amazing and Im
interested to talk about home birth. But I dont
think I have enough courage. Because I want to
be somewhere where if I need help its close.
And I know that home birth is not supported in
any [case] by the health-care system. But if you
decide to give birth at home, you have to ght it
through.
(Kati, user)
Further, the want of courage was a feature in a
number of other maternity-related decisions.
These included midwives perceptions of their
own decision making in relation to the place of
birth and their preparedness to attend a birth at
home:
If the woman wants to, she should have it at
home, but in Finland there is no system to take
care of mothers at home. I know that in England
you have that, that they can choose. But we do
not have it. I am not brave enough.
(Jaana, midwife)
This sense of not being brave enough contrasts
with the ndings of Browne (2003) in Australia. The
Finnish midwives feelings of vulnerability were to
some extent associated with uncertainty about the
status of home birth and their legal position:
We dont have a home birth system ofcially in
Finland. There are a couple of midwives in
Finland who go to help women to give birth at
home. But its not ofcial. We havent got that.
Now I think here in this area youif someone
asks you to come and help her birth you cant say
it out loud. You have to hide it. And you have to
say little. I know its a little naughty.
(Minna, PMM)
645
There is considerable misunderstanding about
the legality of home birth in Finland. The situation,
however, is claried by Viisainen (2001):
home births are legal and midwives can legally
assist in them (p. 1110).
Sub-theme of place: being safe
The rationale for such covert decision making
was invariably related to issues of risk and safety.
The perception of the greater safety of hospitals
featured prominently, especially among the profes-
sional groups:
because its so safe to be in hospital.
(Teija, PHN)
It is safety. A safe place to be born.
(Pirkko, PMM)
Its safe and they trust the [hospital]. I think
they feel very safe. And I think that safety is a
very important thing. Safety means that they
take good care of them.
(Kirsti, PHN)
Another midwife who met the researcher for a
conversation having just attended a home birth
explained her preparations to ensure safety. These
entail a risk assessment and advising the woman
about the safety issues. Her rationale for going to
the womans home was that a woman who had
decided to give birth at home is safer with a
midwife in attendance than alone with her partner.
Other midwives were similarly accepting, but had
not yet decided to become actively involved:
I am not ready as a midwife to take care of a
home delivery. I dont feel comfortable. I need
this hospital. I am happy for the doctors to be
around. But if a mother wants to have her baby
at home, so, its her decision.
(Jaana, midwife)
Although the focus of safety was almost invari-
ably on the woman and baby, the possibility that
the safety of the midwife (Campbell and MacFar-
lane, 1990) might be an issue was also implied:
Im so technical. I think its safer with us here in
hospital. I dont think it is safe to be at home.
(Kaija, midwife)
The sub-theme of place corresponds with van
Manens lifeworld existential of spatiality to facil-
itate reection which leads to contemplation of
safety.
 ARTICLE IN PRESS
646
Sub-theme: playing the system
The midwife who had just attended a home birth
talked in some detail of the strategies which were
required to conceal the activities which resulted
from her decisions. Some of her colleagues, who
colluded in and supported her covert activity,
recounted their part as has been mentioned already
(for example, Minna, a midwife and manager,
above):
These [matters] are informal. The mothers
know people and the Active Birth Society know
people and therefore home births. But nobody
knows about ityknow ofcially. We dont
have any instruments and material because the
Society doesnt have any. They have to borrow
them from [y] here. And this is why we have to
do it in secret. Everything in secret. Its very
unofcial.
(Heli, midwife)
A mother, after the tape had been switched off,
recounted her experience of implementing her
home birth decision. Thus, from the researchers
reective journal:
She was prepared to go into the hospital if it
became necessary. She didnt tell many people
beforehand. Just her husband, who was quite
happy, and her best friend. Another friend had
given birth at home 1 year and 55 minutes before
she did. The labour for the home birth was quite
quick compared to her previous birth, about
5 hours, although the latter part was very rapid
[womans emphasis].
(Aino, user, journal notes)
Such place of birth decisions, like this womans,
may be regarded as resisting the system or even
subversive. They also resonate powerfully with the
moral danger to which Viisainen (2000b) found that
women choosing home births exposed themselves.
As well as place of birth decisions, the researcher
was given other examples of how the informants
would buck the system. Challenging established
ideas about baby feeding and other aspects of
neonatal care emerged frequently in this sub-
theme:
Well probably during my second pregnancy there
were some things that I tried to do differently or
I tried to suggest something different. I was still
nursing [my daughter] and the nurse at the
neuvola told me that You have to stop now.
And I tried to bring her some books and say Well
can we discuss this because I have read in these
books that that its not maybe necessary right in
R. Mander, H.-L. Melender
the beginning at least? So she said Oh those
books! Theyre all written by some fanaticsyou
dont want to be some kind of an extremist or
something. You dont want to. They are not
really something that you can take seriously. So
she dismissed the whole issue like that.
(Susanna, user)
There were also many examples of informants
taking advantage of the system in other ways to
assume power to operationalise their own choices:
Anyway I chose to go to [hospital A] 3 days after
my due date. Because every time I had contrac-
tions I cried. And I felt kind of stupid to cry, after
the contractions because I wasnt afraid of the
birth. I was afraid of the hospital [B where I
was booked]. Then I called [hospital A] and it
sounded so nice, I immediately decided to go
there. And when I was in labour, then I just went
there and they werethey were like Oh! OK
youre here. We dont have any papers but y so
it cant be helped.
(Kati, user)
The midwives working in maternity units also
take advantage of opportunities which present to
play the system. Some opportunities appear on a
regular and predictable basis:
At the day time of course there are doctors who
give rules and its different. But at night and in
the evenings then we have more possibility to
make decisionsto make decisions more.
(Minna, PMM)
Thus, it became apparent that each of the
three groups of participants was taking the oppor-
tunities that presented themselves to put into
operation their own decisions in contradiction to
the policies of the health system. These decisions
represent further examples of the lived nature of
communality.
Discussion
This study explores the meaning of choice and
decision making to the participants in one parti-
cular maternity setting. In this situation, the
background theme of trusting the system pro-
vided a crucial backdrop to the making of choices
and decisions. The context of a well-trusted
system, together with admirable skills in obtain-
ing information, enabled the informants to feel
safe and secure in making decisions and oper-
ationalising them in a changing world. This was
despite the feeling that they lacked the courage
 ARTICLE IN PRESS
Choice in maternity
and strength to implement decisions that could
engender unfavourable reactions.
The nal sub-theme playing the system shows
to what extent the informants were able to make
the most of the well-trusted system. It is clear that
the context of trusting the system was crucial in
making the informants sufciently secure and safe
to permit them to challenge the system they
trusted, yet perceived as not particularly exible.
This challenge to authority is a form of responsible
subversion of a well-respected system; although of
a supremely high quality, the system allows little
scope for some individuals to express their choices
regarding care or practice.
The subversive activity identied in this mater-
nity setting may be construed as a form of
resistance which is both enhancing and disruptive.
This is comparable with the argument by Foucault
that the exercise of power inevitably engenders
resistance to it; thus there is a self-limiting aspect
of sources of formal power and authority (Dreyfus
and Rabinow, 1982). It is possible to further
interpret such resistance as reecting an assump-
tion of some degree of power, which may be moral
rather than political. Such an assumption of power
has been identied previously among childbearing
women (Viisainen, 2000b; Kornelsen and Grzybow-
ski, 2006). Such power contrasts markedly, how-
ever, with another form of resistance which has
been attributed to midwives. This is the doing
good by stealth (Kirkham, 1999, p. 736), which
carries connotations of oppressed group behaviour.
The activities of these three groups in the
present study in subverting the maternity care
system further resonate with studies undertaken in
a nursing and midwifery context (Hutchinson, 1990;
Peter et al., 2004). Although responsible subversion
is clearly not unknown among midwives, it has not
been possible to nd documentary evidence,
except for Edwards (2001) brief allusion. Peter
et al. identify the prevalence of subversive activity
and indicate the high moral stance which such
activity reects.
Peter et al. also emphasise the crucial need for
collaborative action in order to achieve culture
change. This recommendation is most apposite; in a
maternity setting, it has been implemented in the
form of a partnership between service providers
and service users, which has met with considerable
success in some countries (Guilliland and Pairman,
1995; Kennedy et al., 2003; Currie and Brown,
2005; Fitzsimons et al., 2006; Freeman, 2006).
The responsible subversion of authority in this
maternity care setting demonstrates a common or
shared approach among recipients, managers and
providers of care. The informants, as discrete
647
individuals, are clearly able to assume power to
make the decisions they consider important. While
regretting their own lack of strength, these
informants assumption of what may be regarded
as an illegitimate form of power contrasts with
their description of themselves as system obedi-
ent. It may be that the co-operation or partnership
between these groups has scope for development.
Conclusion
The outstanding conclusion which emerged in this
setting is one which is likely to inform policy
making in other countries. This nding applies even
if those who are involved with the maternity
services regard themselves as lacking the strength
to make decisions, in that they are neither well
organised nor acting cohesively. The conclusion is
that if choice is not made available, responsible
subversion may be employed as a way of assuming
power, in order to appropriate choice. In this event,
power and control over the childbearing experience
may be assumed by other, possibly subversive,
means.
Acknowledgements
As well as the contribution of the informants, the
nancial support of the British Academy and the
support in kind of the Department of Nursing
Science in the University of Turku, Nursing Studies
in the University of Edinburgh and Turku University
Hospital Research Foundation is gratefully acknowl-
edged. The helpful advice of Professor Valerie
Fleming is also acknowledged with thanks.
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