Abstract
Reporting on the development of an ongoing qualitative research project with clients of midwifery care in New Brunswick, Canada, this article details the ways that methodology is complexly interwoven with political praxis. Working through the development of this project, this article models one way to enact politically engaged feminist research at each stage of the research process, from developing the research question, through research design, data collection, analysis, and theory generation. In the process, three core principles of feminist research methodologies are extended: co-construction of knowledge, researcher reflexivity, and reciprocal relationships in research. This research is caught up in and responds to a fraught political context where supports for reproductive healthcare are limited, and midwifery, abortion, and gender-affirming care are all framed as “fringe” services that exceed the austerity budget of the province. Participants engaged in this study with a clear understanding of this political terrain and approached interviews as an opportunity to share their experiences, and to advocate for the continuation and expansion of midwifery and related services in the province. Through the research process, it has become evident that midwifery must be understood as part of the struggle toward reproductive justice in this province. These reflections will direct further stages of the project, including ongoing research and dissemination.
Keywords
Feminist qualitative methodologies are particularly well-suited to addressing the relationship between political praxis and knowledge production. While there are many excellent articles and books explaining various approaches to feminist research, there is less available for researchers looking for in-depth explanations of the process of feminist qualitative research outside of coding and data analysis. Gustafson's (2000) analysis of the literature led her to conclude that Feminist research is political in standpoint…, gendered in focus…reflexive in process…and transformative in outcome (p. 781). She goes on to note I have not found these elements presented succinctly as a conceptual framework for feminist research. Furthermore, these elements appear to be common to all feminist research despite its multiple and sometimes contradictory forms. (p. 781)
Oppressive power operates in society as embedded patriarchy within structures and institutions that produce knowledge (Harding, 1991). Institutions like the academy, healthcare and medicine, science, and others are granted authority to shape what we know. These authoritative structures, and the resulting research, generally reflect a commitment to objectivity, where there is a truth that can be found through empirical study that treats the observer/empiricist as unimportant in the process (Harding, 1991; Hesse-Biber & Piatelli, 2007). Feminist research pushes back on this, through a process of reflexivity, whereby the processes of power are made visible in research, and the researcher is not seen as separate from the process of research (objectivity), but instead it is made clear that someone (the researcher) is doing research and this person has a social position that influences the way in which evidence is collected, analyzed, and disseminated (Haraway, 1988; Harding, 1991). Feminist researchers believe that attending to and subverting an oppressive enactment of power is aligned with a commitment to reciprocal relationships, resulting in new knowledge that can be used toward emancipatory ends.
Because the academy and institutions of science and medicine have been for generations dominated by white men, there are large gaps in what we know about the lived experiences of anyone else (Letherby, 2003; Smith, 1987). Feminist researchers are committed to addressing these gaps by beginning in the everyday lives of marginalized people (Smith, 1987) which requires the flattening of power hierarchies to the extent possible. This opens the door to reciprocal relationships between researchers and participants, where knowledge is not harvested, but where researchers and participants come together to create new understandings, for mutual benefit, which flow out into the broader social world (Letherby, 2003). By embracing power not just as oppressive force, but also as potentially emancipatory, and by creating knowledge in and for community, we can see how these theory-based values result in new research methodologies wherein researchers practice humility, reflexivity, and reciprocal roles in knowledge creation and mobilization.
In this article, we detail how the methodology we develop in this study is complexly interwoven with praxis by sharing some concrete examples of how we are enacting politically engaged feminist research in our study. The principles that guided our research are: co-construction of knowledge, researcher reflexivity, and reciprocal relationships in research. These principles shaped every aspect of the research process, beginning with community consultation and moving through a process of informed consent, leading into feminist approaches to interviewing, including attention to interview location and a semi-structured (and at times unstructured) approach to interviewing. Our approach to this research reflects our deliberate attempts to flatten the hierarchies of knowledge and power that are often inherent in research. This article does not focus on the findings from this research; instead, we provide a glimpse into our research process, to provide some concrete illustrations of the processes and challenges involved in the political work of feminist research on midwifery care in this specific context.
Project Overview
The researchers are both cis white women who have delivered babies. We are both pre-tenure academics with comfortable middle-class lives. CM had three pregnancies and births which she delivered in hospital-based births in the 1990s and early 2000s. KJ had midwife-assisted home births in Toronto in 2007 and 2010. Both live and work in New Brunswick, the technical jurisdiction where the research is taking place, but approximately 2 hours away from Fredericton, the city in which the only midwifery practice in the province is located. This project was originally conceived of as a next step to CM’s doctoral work regarding childbirth distress (MacDougall, 2020). She had originally imagined a project exploring the barriers to perinatal mental health support in the region and reached out to the midwives working in Fredericton to explore the possibility for collaboration. Given her interest in midwifery and access to services for marginalized populations, KJ was eager to collaborate on the project. Beginning in the summer of 2019, we interviewed 28 clients of midwifery care in and around Fredericton, New Brunswick, as well as their partners and other support people. 1
The context in which this research occurred was, and remains, politically charged around issues of reproductive care. In New Brunswick, the retrenchment of reproductive and related healthcare has resulted in struggles over access to such healthcare in the region (Johnstone, 2018; Kirby, 2018; LeBlanc & Kornelson, 2015). This politicized reproductive healthcare landscape includes debates around (lack of) access to abortion and midwifery care, unattended home birth (free birth), and difficulties navigating obstetricians, nurses, and other care providers.
In response to calls for access to midwifery services in New Brunswick, the Fredericton Midwifery Centre was established as a demonstration site in Fredericton in 2017. The center falls under the jurisdiction of Horizon Health, the provincial anglophone health authority. Initially, the center was staffed with four full-time midwives, an office administrator, and one shared manager. From 2018 until late 2020, staffing at the center was reduced to 1.5 FTE midwives as a result of pregnancies and leaves. Since its inception, the practice has served more than 100 clients and maintains an equally long, and steadily growing, waitlist.
From the outset, it was clear to us that the underfunding and under resourcing of midwifery services, with a maximum of four midwives in the entire province, was part and parcel of the long history of inadequate reproductive health services in the province. Due to the limited catchment area and staffing shortages, many who want midwifery care have been unable to access this service. In addition, some people seeking midwifery care made difficult changes in their lives in order to be eligible for service. For example, some participants in our study went on leave from work early and rented accommodations within the catchment area weeks before and after giving birth, including some who delivered their babies in AirBnBs. Others drove long distances, sometimes hours, across the province in order to have prenatal visits with midwives. Many people who wanted to have home births were unable to do so, as staffing shortages meant that these plans could not always be accommodated.
In developing this project, it quickly became clear that our research would need to engage the charged political context in which we were working. As we work with the data from this study, we come back repeatedly to the relationship between reproductive justice and research on birth, and we continue to reflect on how best to address this relationship as we continue our research. Reproductive justice applies the lens of intersectionality and social justice to reproductive rights, creating a new field of scholarship and activism (Price, 2010; Ross & Solinger, 2017; Smith, 2005). Reproductive justice was developed by women of color in the United States in the mid 1990s and highlights how people experience oppression in their reproductive lives differently in relation to their social location (Ross & Solinger, 2017). The movement has at its core the claim, “all fertile persons and persons who reproduce and become parents require a safe and dignified context for these most fundamental human experiences” (Ross & Solinger, 2017). Given the framing of reproductive justice, we kept coming back to the importance—and the challenges—of connecting our research to a reproductive justice framework. Eventually, the crucial importance of connecting birth justice and reproductive justice to our ongoing research program became undeniable. In the following pages we describe and analyze concrete aspects of the process of developing and conducting this research, and then return to the ways that this project has raised questions for us about the connections between birth justice and reproductive justice, as well as our roles and responsibilities as researchers.
Shaping the Research Question: Consultation With Community
In the fall of 2018, we met with the midwives working at the Fredericton Midwifery Centre, which was a demonstration site at the time. The midwives filled us in on the long-term struggle to develop midwifery services in New Brunswick generally, and specific issues regarding access and support for the program. The midwives we met with were interested in hearing about how their clients were finding the program, what was working well, and what could be improved. Following this meeting, we developed a research plan for two phases of research; the first focused on clients’ experiences of midwifery care in New Brunswick, and the second exploring midwives’ experiences of providing care using composite case studies developed from our interview data. These first two phases have been conducted in collaboration with Horizon Health. Our aim was, and remains, to develop a research agenda that will be of use to the midwifery practice community in the province. At the time of writing this article, we have completed the first phase of the project and are recruiting for phase two.
From the very early days of this project, the feminist values of reflexivity and reciprocity influenced how we proceeded with the study. As researchers we are acutely aware of the power we hold in how we shape the research, which stories are shared or marginalized, and the power that academic authority has to shape dominant knowledge and potentially policy and practices that are “evidence based.” Practicing reflexivity means paying attention to how our various social locations influence the research process at all stages, beginning with what particular focus the research takes and what questions are addressed as the project unfolds (Hesse-Biber, 2007, 2014).
Originally, our envisioned project arose from CM’s interests and was more in line with her PhD work, with a focus quite removed from the current study. Upon consulting with the midwives, it became quickly evident that a different kind of research was needed in order to align the research with community needs and in keeping with our own commitments to leveraging the institutional and structural power we hold as academics to be helpful to people “on the ground” even if it might be more time and labor intensive than we had originally anticipated.
The feminist value of reciprocity also informed the earliest stage of research. Reciprocity is a political approach to research where there are concerted efforts to flatten the power relationship between the researchers and participants and to engage in research that is mutually beneficial (Huisman, 2008). As pre-tenure academics, we are expected to have an active research program resulting in published works. Clearly, this research has the potential to benefit our careers, even if it is not useful to the midwives and those seeking midwifery services in the region. However, our valuing of reciprocity means that in order to be ethical feminist researchers, our research questions and projects must not be extractive and instead need to benefit the community with which we are engaged. At various times throughout the process, we touched base with the midwives to update them on our progress and make sure that the research was continuing in a productive direction. Because reciprocity is closely linked with reflexive research (Huisman, 2008), we also directed (and continue to direct) a great deal of deliberate attention to our positions of power in this research. This means treading carefully on topics that might impact the safety of various members of the community, or that might cause discord for the midwives within the healthcare community, even if these topics would make interesting research findings. This is not to say that we did not pursue these topics—indeed we did—but we proceeded with great caution, thinking through how we could and should use our positions to move important topics forward without creating harm.
The Ethics of Informed Consent
After consulting with the midwives and developing a new research plan, we undertook the requisite research ethics review processes through both our university and Horizon Health and began recruiting for the study. Within an hour of posting our ad on social media, we heard from many people interested in participating in interviews. While the urge to jump right into data collection was strong, our commitments to ongoing and engaged informed consent were prioritized. Once potential participants expressed interest in the study, we sent the full informed consent document and interview questions for them to review. We asked participants to let us know if they remained interested in the study once they had reviewed these documents. We also answered any questions potential participants had before they met us in person. We felt this was important so that potential participants would be truly free to not participate in the research if they were uncomfortable with any aspect of the study, as we were concerned that it would be harder for participants to change their minds about participating in the study once we were face to face with them. Providing the interview questions in advance also allowed participants to be fully aware of what sort of questions we would be asking, and what kinds of information we were collecting. This also allowed participants time to reflect on the questions we planned to ask so that they could share the information they wanted to share, and also think about what information they might want to keep private. Several participants prepared for the interview using these prompts and referred to notes they had made on the document throughout the interview.
A process of meaningful and informed consent is also part of reciprocity. As discussed, as researchers we will likely benefit from the study. Allowing participants to have all the information we could give them so they could make informed decisions was a way of showing respect (inherent in reciprocal relationship), as well as allowing participants the time and space to decide for themselves, without pressure, whether taking part in this study would be useful for them.
Informed consent did not end once the official consent forms were signed at interviews. Throughout interviews, participants were reminded that they would have the opportunity to decide whether everything that they said “on the record” should be included in our data, or whether they might want to add anything. Once the interview recordings had been transcribed, we sent these to each participant and asked for feedback on how the transcripts should be used. Many participants requested minor changes (e.g., a name had not been deleted from the transcript, a place name was wrong), and others asked for more substantial work on their interviews. Some participants, after reading the transcript of their interview, asked for specific sections of the transcript to be deleted, or for it to not be used as a representative example in any publications. Reasons for these requests varied, but all requests were honored without question. Sometimes, transcripts were sent back and forth multiple times until the participant was happy that the transcript reflected the story they wished to tell. This was an important way of demonstrating the value of participants’ contributions, and of conveying the care with which we planned to work with their stories. In this way, the relationship initiated with the first contact and sharing of informed consent documents and built through the process of interviews, was maintained throughout the research process.
Feminist Interviewing
Where to Conduct Interviews
Our typical interview setting would be familiar to many feminist researchers: we met participants in their homes, chatted on their decks and balconies, or in their living rooms and kitchens, and met their babies, children, pets, and sometimes members of their extended families and support networks. Some interviews took place in workplaces or at the midwifery center in Fredericton, others at a favorite cafe. Both researchers were present for about half of the interviews, ostensibly leaving one person to hold a baby or play on the floor with a toddler while the other conducted the interview, but usually resulting in both of us engaging enthusiastically in the interview, interjecting questions and contributing to the conversation while playing peek-a-boo or reading a board book with a little one. As researchers, we had the opportunity to “ooh” over newborns, hold sleeping babies, and delight in toddlers who wanted to hand us their toys, dig through our bags, or reach for the tape recorder, with its enticing buttons and lights. While presenting some challenges, these research settings were certainly the most suitable to our project and in keeping with our commitment to feminist research that is attentive to dynamics of power.
In particular, we felt that meeting participants in places where they were most comfortable was a way of enacting reciprocity. We were aware that asking new parents with young children and infants to meet with us for an hour (sometimes more) was a big ask. Being willing to meet in their homes, chat on their couches, while helping to wrangle children, burp babies, and wipe spills, felt like a way to respect the lived reality of new parents’ lives, as well as a way to carry the discomfort that can come with venturing into the unknown. We the researchers were the ones who felt the nervousness of not knowing what to expect or how we would be perceived. Certainly, it is likely that participants also shared some apprehension about two strangers coming into their homes, but we hoped that by moving in their spaces we sent a message of respect and vulnerability that helped to even the power relationship between researcher and participant. It seems that this was effective. We were regularly offered tea, invited to stay longer and visit, and often exchanged hugs with participants on our way out the door.
Mutual Disclosure
Another way in which feminist researchers endeavor to reduce hierarchy in research is through mutual disclosure, which meant we did not just ask questions of participants but also responded to many questions participants posed to us about our own lives and our own birth experiences (Hesse-Biber, 2014). Many participants invited mutual disclosure, seeking to know a bit more about us and our orientation to the research before sharing their own stories and experiences. Participants often asked about our own birth experiences. A typical example of mutual disclosure is reflected in the following interaction between KJ and participant Wynn 2 :
So, did you have yours at home.
I did.
Sorry, if you don’t mind me asking.
Yeah. I was in Toronto. Under the Ontario system, it was a family friend, which made a big difference.
Who was a midwife?
Who was a midwife. Yeah. It wasn’t a free birth situation at all, and in the end, my first birth was very quick. It was January, there was supposed to be two midwives but only the primary made it.
Oh my gosh.
These mutual disclosures were part of normalizing the experience of the interview, of building relationships with participants and of approaching interviews as a conversation in which all conversation partners have a role (Lather, 1988; Stern, 1998). Another example of relationship development through mutual disclosure was evident in relation to our own positions on midwifery care, as participants frequently felt protective of their experiences and of midwifery more broadly. Mutual disclosure was often invited as a way of establishing our political orientation to the research, and we soon developed a practice of clarifying our commitments early in interviews.
Now as we review the transcripts of the interviews, we see our voices are present in a way that may not always be conventional in qualitative interviews. While both mutual disclosure and extensive member checking might be critiqued for shaping the data in biased ways, we believe these approaches are aligned with feminist ethics of responsibility to each other and to our communities. This approach is also aligned with non-positivist views of knowledge and knowledge production wherein truth is viewed not as something to be extracted but where knowledge is something that is socially constructed and co-constructed through and in relationship (Hesse-Biber, 2014; Moosa-Mitha, 2005).
Relationship Building: How to Listen
We worked to balance mutual disclosure and researcher involvement with “staying out of the way” and letting folks tell us their stories, for example, through the use of open-ended questions and not interrupting if the topic veered away from our anticipated direction. Some participants were prompted to participate in interviews out of a desire to have their birth stories heard, to share insights gained and have the opportunity to talk through their experiences, and this was also something that we wanted to honor. For example, at the end of our interview, we asked Alexandra if there was anything else she wanted us to know and she said “I think that we’ve touched on quite a bit, and I’m comfortable with where it’s at. I feel heard.” Similarly, Jessica shared some painful experiences in her interview. We were both moved by her interview and at the end thanked her for sharing her story. In response, she said:
Thanks for giving me the opportunity to discuss it. It’s not that often that I get to talk about it!
And that’s part of the reason I think we should talk about it. As part of feminist research also, like, I don’t think research should just be us coming in and harvesting your story and leaving. If this can be useful to you to have like, understanding, non-judgemental people who just want…of course!
I think just being able to say it out loud and feel that there, I mean there can be judgment, but like, I know you’ll keep it to yourself…then it’s nice. It’s new. It doesn’t happen.
We noticed that as our study progressed, more and more participants mentioned that they had heard about us from friends who we had already interviewed. While this is typical in snowball sampling, we also believe this word-of-mouth referral demonstrates some success with enacting our feminist principles of reflexivity, reciprocity, and knowledge co-construction. We believe participants co-constructed knowledge together, in their community, about our trustworthiness as researchers in regard to sharing private, and at times sensitive information that could have repercussions at individual and policy levels. In this way we also see snowball sampling as a form of co-construction of knowledge and as a test of the validity of the feminist research process.
Co-Construction in Interviews: How to Make Meaning
Reflexivity is linked with co-construction of knowledge in this study. As we actively reflected on what we heard in our conversations with clients throughout the research process, we made conscious decisions about how our positions of power should shape the research question and process in order to best meet the needs of the community who provide and receive the service. This is in deliberate opposition to positivist ideas about objectivity and neutrality. Most interviews began with a very open-ended question, inviting participants to tell us what they wanted us to know about their midwifery experience. Instead of sticking to a preordained interview script, where every participant was asked the same questions, we updated our interview guide as we became aware of new issues (often political in nature) and had frequent discussions between the two of us as to the implications of the changes we were making.
Feminist commitment to knowledge co-construction is a deliberate move in anti-oppressive research, rejecting ideas of a singular truth with authoritative knowers who collect and report truth through research. Instead, in anti-oppressive feminist approaches, research begins from the premise that knowledge is created through and in relationship to each other, and is linked to subject positions (Moosa-Mitha, 2005). A feminist perspective on the co-construction of knowledge views the in-depth interview process itself as the vessel in which meaning is co-created between the researcher and the participants (Hesse-Biber, 2014). Hesse-Biber (2014) reminds us: “The researcher must stay on his or her toes and listen intently to what the interviewee has to say, for the researcher should be prepared to drop his or her agenda and follow the pace of the interview” (p. 203).
For our study, in-depth interviews allowed for the co-constructing of knowledge about midwifery care. This meant arriving at interviews prepared with questions and prompts that were important for us as researchers to address but, more importantly, it meant that we engaged in deep listening—paying attention to what participants said that surprised us, that contradicted our own ideas about midwifery care, and that challenged dominant ideas and marginalized ideas about midwifery care.
It also meant listening to what was not said—moments of seeking to find the right word and failing, moments of communication through nods of the head, eye contact, guttural laughs (Devault, 1990). An example of this occurred in an interview with a lesbian couple. The non-pregnant partner, Marie, discussed her role in the birth as being more profound and involved than she, or she expects others, anticipated, and she credits the midwives for honoring their family’s needs and for centering both partners in the birth experience.
I wanted to do it, but like I said I’m not into blood, I’m not into…Like he poops and I’m like “Ugh” kind of thing.
Wet things. Yeah, we don’t like wet things.
Anyways, so I thought that was a really, really cool but really personal experience for me. Khloe didn’t even see it, you know what I mean?
I saw the ceiling.
So, any time anybody asks, they’re like, “What, you really did that?” I’m like, “Yeah, my midwife, blah, blah, blah,” and they’re like, “That is super cool,” so not a lot of people can speak to that, but I can, and so I kind of brag about it sometimes. Anyways, so I am really excited that I got to do that, and I wouldn’t have it any other way.
Because you basically brought him into the world. I just carried him, but you were the first…
I cut his umbilical cord. She allowed me to do that too. I was like, “Oh my God.” Like I said, it was really a personal experience.
In this excerpt we can see that many of the details one might expect to be important are replaced with “blah blah blah,” an affect of disgust gets replaced with “ugh,” and when Marie could not find exactly the right words to describe her profound experience, she looked for our understanding by saying “you know what I mean?” Finally, the awesome feeling she experienced was captured by the phrase “Oh my God.”
Sometimes, co-construction meant that the interview went in a direction that had little to do with our interview guide. As feminist researchers working with participants together to co-construct knowledge and meaning, we needed to be open to these experiences. This requires a willingness to let go of the power inherent in the research interviewing process (as much as researchers can ever let that go) and moving in the direction the participant wanted the interview to move. An especially poignant example of openness to new directions occurred in an interview where questions about the importance of access to midwifery care quickly turned to a discussion focusing on the participant’s experience of navigating a decision to have an abortion when she was told her pregnancy would result in a baby with a disability. This participant was challenged by what she felt were competing values and interests. As someone who advocates for both abortion rights and disability rights, these ideas were no longer strictly beliefs she held, and she shared her story of struggling with the loneliness and fear of judgment that were part of her experience of making the decision to have an abortion. Many of our questions about midwifery remained unaddressed in this interview and instead we were able to understand in a new way how access to midwifery care is embedded within a reproductive justice framework.
Another way in which knowledge co-construction occurred was through deep probing of words and ideas that might have been left unexplored if we had strictly followed our interview schedule (Hesse-Biber, 2014). For example, we did not introduce the concept of “empowerment” in the interview guide, but this idea came up frequently in the interviews. When it did, we probed into what participants meant by “empowerment,” going off-script from the interview guide, and we came to think about these concepts differently through our conversations with participants and each other. An example of this occurred in our interview with Rebecca, where our thinking about empowerment also came to include ideas about what we consider informed consent:
You used the word “empower” and that’s a word we hear a lot in these interviews. Could you—are there any other ways that you found that, that word comes up when you think about your experience with midwifery?
Um, that’s a good question. I am trying to articulate…I just, I felt like I was in control of the choices, even small things. Like they would ask before touching me, and they would tell me what was going on. So, I felt like I had a lot of control over all of the medical appointments.
This was an important moment in our understanding of how participants experienced power operating in consent processes and shaped interviews that followed, as we paid attention to ideas of power and consent in new ways.
Team-Based Interviewing & Co-Construction of Knowledge
As Hesse-Biber (2014) notes, “Reflexivity is particularly important when conducting team-based research” (p. 201). We are fortunate that we are a team of two researchers, and while our social locations and world views are similar, we also found that while we were “in the field” each of us would bring our own wonderings and analysis to the interviews. We figured out early on that two researchers are better than one—both for practical reasons (one person to navigate, the other to drive; one to lead the interview the other to play with babies), and because we have different experiences and strengths that all benefit the research process.
As we are now analyzing the data, we notice that at times during the interviews there are three of us constructing meaning in conversation with each other. CM hears/interprets one thing, KJ hears/interprets another, and the participant(s) share their analysis with us as well. This results in new understandings of ideas that might have remained uncontested if the interviewers approached knowledge as something to be discovered rather than knowledge as something that is produced through relationship and reflection (see also Hesse-Biber, 2014, p. 215). Areas of misunderstanding or differing agreement create tears in the positivist fabric of knowledge that highlight the limits of a single perspective.
The co-construction of our analysis was and remains an ongoing process of dialogue. Discussions in cars, in hotel rooms after meeting with participants, over dinner, and now virtually, during our weekly research meetings, continually result in meanings neither researcher would be likely to develop alone. This manifestation of reflexivity and co-construction in data collection and data analysis moves against pressure to standardize the research process and creates opportunities for these unique and deep meanings to develop.
Reflecting on Power in Research
Many participants in this study were committed to contributing to our project and to the social change they hoped would result from more attention being paid to midwifery services (or lack thereof) in New Brunswick. As Evelyne said at the end of her interview: Oh, you’re welcome! You know, hopefully, um, some people will get the chance to come across these stories and well, maybe, be able to change their mind about what this all is, what this all can be. Yeah.
What became clear to us is that participants, researchers, and midwives are all using the power we have access to in order to make changes beyond ourselves. Although some participants shared that they were glad to have an opportunity to talk through and share their experiences, none anticipated significant personal benefit from their involvement in this study. Most were very clear that their experience with midwifery care is likely over and that their involvement with midwifery was such a profound experience for them that they felt obligated to speak up in order to create better conditions for those who come after them.
Several participants spoke of a reciprocity between themselves and unknown future parents, and as a way to give back to their community more generally. In these expressions of reciprocity, many participants also reflected on their own positionalities. For instance, several spoke about the screening practices undertaken by the midwives which aim to prioritize access to midwifery care in accordance with understandings of the social determinants of health, including racialization, Indigeneity, socio-economic status, gender identity, and sexual orientation. Numerous participants were aware that they did not necessarily “check the boxes” of this screening and expressed a clear sense of their understanding and support for this policy even if it meant they would not have access to the kind of care that they were seeking for this or a subsequent birth. As Margaret explained: I know that they do their intake based on priority demographics so I was a little bit stressed about that cause I was like “okay we’ve been fighting for midwifery for years and we’re not going to have one but it’s okay people who need it will get it” and…just sort of went through that whole thing in my mind where I was like “okay we might not get a midwife again” and try to be okay with that because the first time I definitely was not okay with it.
Taken together, reciprocity among researchers, midwives and clients is evident. But there is also an awareness of the fraught political context, a fear that midwifery services, rather than being expanded across the province, will be dismantled under the guise of austerity. Developments in the fall of 2020 suggest these fears are not unfounded.
Methodology and Theory as Iterative Political Praxis
Politically engaged methodologies that are rooted in politically focused theories, yield politically important insights. We are currently struggling, even as we write this, with how the politics, ethics, and issues that participants and stakeholders shared with us indicate that midwifery care should be part of a reproductive justice framework and how these reflections should shape future research. For instance, we are unsure how to talk about and employ a reproductive justice framework in this context given the overwhelming whiteness of ourselves and participants. How can we argue for midwifery care as part of reproductive justice without appropriating or taking away from the work that needs to be done regarding other aspects of reproductive justice in this province and region, especially in regard to BIPOC access to reproductive care? These questions have only emerged because of the politically engaged and theoretically-informed approach to feminist research that we have enacted in this study.
A more conventional qualitative study would have been different at every stage, from the development of the central research question, through to research design, findings, and dissemination. We might have arrived at some similar findings using a more conventional approach to research design. For example, it is likely that a survey or more structured interview process would have yielded similar insights about client satisfaction and the strong desire for expansion of the program. But it is unlikely that our findings would have been as richly detailed, or that we would have gained such a clear understanding of the complex interconnections between social location and access to power, and between birth justice and reproductive justice, including access to abortion. Following feminist theoretical and methodological commitments meant that our research direction changed drastically after our consultation with the midwives, altering the course of the study at an early stage. Similarly, our commitments to attending to relations of power within the research relationship mean that informed consent continues to be an ongoing rather than procedural process, which sometimes means that we need to remove, rephrase, or reconsider how we share the insights of participants. It also means that interviews are driven by participants, rather than a set survey instrument or interview guide, which can mean that interviews take new directions with little notice. Usually, these new directions were immensely productive, becoming moments of co-construction of knowledge rather than knowledge extraction. Often, new directions have also meant a need to actively hear and respond to deeply emotional narratives and traumatic experiences around birth and access to reproductive care in the province.
The most troubling finding from our research so far is that the structure of the midwifery program in the province reflects long-held interconnected ideas about bodily autonomy and the gender order in our region, with devastating impacts on those seeking reproductive care, and often on care providers. Existing policies addressing reproductive and sexual health in the province of New Brunswick paradoxically act to perpetuate harm, through the lack of resources, rather than ameliorating the problems they are meant to solve. One popular narrative among politicians constructs midwifery as a “rich people,” boutique kind of care and it is easy to see how this serves to disincentivize advocacy for midwifery care from the political agenda while/by removing midwifery care from the reproductive justice focus. Midwifery care in New Brunswick parallels the province’s approach (or lack thereof) to abortion provision. In this province, publicly funded abortions are only available in hospitals and only in three locales. Other community-based, non-hospital abortions had been provided as a private (out of pocket) service at a clinic in Fredericton, which closed in the fall of 2020 due to a lack of funding. In this context there is government hostility to women’s health, which can be shown in action, but also in inaction and devaluing of reproductive care and sexual health care. Other examples of this include family resource centers being privatized, and the lack of a perinatal mental health program in the region. By providing a small, under resourced midwifery program, the government can be seen to be responding to calls for expanded reproductive care in the same way that by providing limited and often inaccessible abortion care the province can position itself as providing abortion care. These programs create the veneer that something is being done when in fact very little is being done and ironically, change is being blocked by discourses of action (Ahmed, 2007).
These findings have challenged us to consider areas that we had not previously identified, and they have yielded a new sense of urgency and commitment to disseminate the research in the interest of immediate policy change and community mobilization. The first output from this study was a report prepared for a community-based organization engaged in advocacy for expanded midwifery care, and as we continue to work with this data we return again and again to the urgency of feminist political action as a core component of this work, connecting birth justice with reproductive justice and shaping the future directions of the research project. As we move forward in our study, we wonder: who benefits when reproductive care such as midwifery care is repeatedly framed as boutique care that belongs in the private sector, and what power relations are maintained in this framing? What kinds of divisions happen in feminist community when this framing is accepted? We believe the “boutique” framing of midwifery care serves to perpetuate a narrative of whiteness in New Brunswick and flattens understanding of various interlocking oppressions. Contrary to what is claimed by the message that it is white women seeking boutique care for their births, the midwifery program in New Brunswick accepts clients into their service based on various markers of social location, prioritizing those from marginalized groups. This clinical activism is erased in the boutique framing and serves to potentially create conflict among residents of the province when austerity discourses are dominant—why should taxpayers and activists care about a program for privileged white women? We believe this strategy of division and the weaponizing of discourses of straightness, whiteness, and cisgender normativity, disincentivizes collective action around reproductive justice in the province. In the next stages of our project, we will continue to consider what to do with these insights, how to incorporate reproductive justice in writing our findings, and how to center political issues in future research protocols.
Recommendations
We leave the reader with some recommendations for engaging in feminist methodologies in reproductive justice research, and we hope these suggestions will be helpful for researchers in other fields as well. 1. We believe there is no such thing as too much consultation as part of the ongoing research process and encourage researchers to check in with their research partners frequently throughout the research process. 2. We recommend writing ethics board protocols to be as open and flexible as possible to account for the fluid nature of feminist research. 3. We believe feminist research requires a relationship of trust and encourage researchers to see that the onus is on the researchers, not the participants, to develop and nurture this trust by centering trustworthy behaviors in the project. This includes steps such as sending all interview materials to participants ahead of time, being honest and upfront about any limits to confidentiality (which may be especially significant in rural research), and ongoing consultation with the community. 4. It is important to set aside adequate time not only to deal with logistical issues (booking interviews, and spaces, securing funding, making introductions to stakeholders) but also time for in-depth interviews, conversations, and reflection while in the field. 5. Researchers should welcome the reality that interviews may go (much) longer than anticipated and should book interviews with ample time between to allow for this. 6. Researchers should enact a willingness to adjust on the fly as unexpected topics emerge and are centered, and as new community dynamics that need tending to reveal themselves. And finally, 7. we have re/learned that two heads are better than one in feminist research. To the extent possible we encourage researchers to find research partners who will be “on the ground” together, managing the day-to-day logistics of research and acting as sounding boards and co-constructors of knowledge throughout the process.
Conclusion
We see this research project as a good example of how a conceptual framework and methods together become methodology, informed by theoretical and political orientation. We came to this project with a clear understanding of the methods that we wanted to use, informed by our political and theoretical commitments. Beginning from a feminist commitment to qualitative research that is attentive to relations of power and regards participants as knowledge-holders in their own right, this project has further pushed us to consider the ways research on midwifery must consider its relationship to reproductive justice. Through the process of undertaking this research, we gained clarity on the ways the conceptual framework of reproductive justice continues to inform our methods, philosophy and theoretical framework.
We continue this project with a reaffirmed commitment to centering the voices of participants and to maintaining an approach to research in which co-construction of knowledge is valued. Our ultimate goal for this project leans heavily toward feminist participatory action research models in which participants, researchers, and midwives all work from the positions we hold to make change beyond ourselves. Many clients of the Fredericton Midwifery Centre were eager to participate in this research in the hopes that it would enact some change in this province. Few of them would benefit personally from the expansion of midwifery, but many expressed that this was such a profound experience for them that they felt obligated to use the power they have to create better birth experiences for those coming after them. We return also to the importance of reciprocity and responsibility. We feel obligated to make this research “of use.” Participants expressed a clear sense of obligation to midwives, a sense that because their midwives advocated for them, now it was their turn to advocate for the continued support and expansion of this vital service.
Footnotes
Acknowledgments
We gratefully acknowledge the contributions and support provided by the following people: The professional staff of Horizon Health, including the midwives and staff at the Fredericton Midwifery Centre, Dominique Richard, Manager of Research Services; and all the participants who shared their stories and insights with us. We would also like to thank the anonymous reviewers for their generous and thoughtful feedback on this paper.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by President’s Research and Creative Activities Fund [grant number 102137] and the Marjorie Young Bell Faculty Fund [grant number 102690] at Mount Allison University.
