Invisible but palpable- gender norms in childbirth : A focused ethnography on woman-midwife interaction and birth practices in two Swedish hospital labour wards.

backgroundSwedish labour care is becoming increasingly medicalised, with rising rates of intrapartum interventions such as induction and augmentation of labour, epidural analgesia, and caesarean section. This study aimed to explore the paradox of the increasing medicalisation of childbirth despite the vast evidence of the benefits of low-intervention physiological birth.

methodsFocused ethnography was used to study woman-midwife interactions during labour and birth and the everyday practices of midwives in two Swedish labour wards. After birth, the women and midwives were interviewed. Thematic analysis was used to analyse the data, and the study design and interpretation of results were informed by a social constructionist view of gender.

resultsThe analysis resulted in three themes, mirroring the pillars on which labour and birth care rests- the labour care organisation, the midwives, and the women who give birth. The organisation was hierarchical and based on traditional masculine values such as rationality, efficiency, and productivity. The midwives tried to balance the needs of the birthing women and the organisational demands of throughput. As action and technological skills are more noticeable and linked to masculinity, and thus more valued than the invisible feminine-coded emotional care work of supporting a woman in labour, the midwives became task-oriented and more focused on 'doing' than on 'being'. This led to more birth interventions, less support for the birthing women, and to occupational stress and stress of conscience for the midwives. Normative expressions of femininity were observed in the birthing women, such as placing the needs of others before their own and acts of compliance, which sometimes led to unconsented interventions.

conclusionsWe suggest that societal gender norms and gender-based hierarchies in combination with modern society becoming progressively risk-laden and technology-oriented, have contributed to an increasingly medicalised and interventionist labour and birth care organisation, where physiological birth is rare. Awareness of how gender norms inform labour and birth care practice may be one way to make visible and to recognise all aspects of midwifery care, as well as help flatten hospital hierarchies, improve working conditions for midwives, promote physiological birth, and limit unnecessary and unconsented interventions for the birthing women.