The Value of Constructivist Grounded Theory in Advocating for Unheard Voices in Contemporary Maternity Research

Abstract

There is growing concern that maternity research trends have enabled the proliferation of medically orientated research methods. While this trend has helped demonstrate the safety and quality of midwifery care, it has also enabled a culture of valuing medical research approaches, over more critical, creative and explorative qualitative research. Consequently, a serious imbalance exists within maternity evidence, the majority focusing on treatment of maternity complications rather than what would benefit the mainstream of low-risk women - perpetuating a culture of medically-led maternity care as the prevailing option. Constructivist grounded theory is one approach that can help address current maternity research limitations. This paper highlights capacity within its processes to ask different questions, embracing diverse ways of knowing and unpacking the importance of research remaining woman-centred. There is a need to prioritise such research approaches, raising the perspectives of maternity users and identifying what matters most to women and birthing people themselves.

Introduction

There exists a serious imbalance in the evidence base of existing maternity research, the majority of which focuses on the treatment of maternity complications, rather than understanding what would benefit the mainstream of low-risk women (Renfrew et al., 2014) and improve experiences of maternity care (Kennedy et al., 2018; Sandall et al., 2024). In 2018, a global alliance of maternity research stakeholders and the World Health Organization (WHO) called for researchers to ask different questions in response to The Lancet Series on Midwifery (Kennedy et al., 2018). The recommendation from this alliance is to prioritise research from the perspectives of maternity users, rather than from the perspectives of service providers, to identify and raise awareness of what matters most to women and birthing people themselves (Kennedy et al., 2018).

A recent paper by Newnham and Rothman (2022) discusses their concern about a positivist quantitative trend in midwifery research, with the ‘systematised’ literature review – which, while perfect for practice-based reviews and recommendations. This approach has somehow become the ubiquitous checklist of our era, incongruously encouraged even for qualitative projects that would be better off with more theoretically positioned and critical reviews and other less standardised approaches (Newnham & Rothman, 2022). Kontos and Grigorovich (2018) argue more broadly that knowledge has been re-conceptualized as an application or product, with more emphasis on the economic productivity of knowledge (e.g. push for innovation) and quantification of knowledge products (e.g. impact and accountability). The centralization of research funding and identified areas of research priority, while understandable, may favour particular kinds of research design that lean toward easily implemented, ‘quick-fix’ solutions within current systems (use of ‘innovative’ technology seems popular), rather than those that may challenge the status quo and seek more fundamental social change (Cheek, 2007; Kontos & Grigorovich, 2018). Whilst these types of opportunities have been beneficial for some researchers who have been able to align their qualitative research interests, the impact on the quality of qualitative research has prompted scholars to critically reflect on their practices within these spaces (Cheek, 2007; Kontos & Grigorovich, 2018). And, raised concern for the consequences of “massage [ing] our research into prescribed forms and formulas” (Cheek, 2007, p. 61).

It is important to resist such tendencies, and ‘tick-box’ methods, because these regimented ways of thinking limit both the possibilities and the intent of qualitative research (Charmaz, 2014; Kennedy et al., 2018; Kontos & Grigorovich, 2018; Newnham & Rothman, 2022). While this trend has been extremely useful for demonstrating the safety and quality of midwifery care, it has also led to a culture of valuing dominant medical approaches to research, such as systematic reviews and clinical trials, over the more critical, creative or explorative qualitative research methodologies. This could be explained, in part, by a need within midwifery to compete with medical research, in content, status and grant funding. And is evident in the over-representation of medically orientated research methods securing funding, being disseminated in peer-reviewed journals (Cheek, 2007; Kennedy et al., 2018; Kontos & Grigorovich, 2018). Although qualitative research is often undertaken at doctoral research level, these factors hinder the furthering of qualitative expertise, and the specialising in qualitative research by senior midwifery researchers as an acceptable career pathway, with increasing pressure to move to mixed-method or trial research in the post-doctoral space (Newnham & Rothman, 2022). However, it is crucial for midwifery research to develop and maintain research expertise in qualitative methods in order to keep ‘asking different questions’ and to facilitate the discovery (and/or rediscovery) of diverse forms of knowledge (Kennedy et al., 2018; Newnham & Rothman, 2022). More recently, there has been a call for a critical branch of midwifery knowledge-making (Ashley et al., 2022). These conversations are important for the further development of maternity care, midwifery knowledge and to improve research impact that such inquiry could have for understanding the needs of women, birthing people, participants, families, communities, and midwives (Kennedy et al., 2018).

We acknowledge many valuable qualitative approaches exist however this paper discusses constructivist grounded theory as one research approach that can overcome the challenges highlighted above, as it seeks to raise marginalised voices and perspectives. Its methods acknowledge the influence of relationships in developing mutual understanding and considers the context in which these relationships exist, how knowledge is shared, exploring divergent processes of data collection, which may be driven by the participants, the researcher, or the analysis (Charmaz, 2014). These principles of grounded theory reflect the midwifery philosophy of valuing the midwife-mother relationship, which acknowledges the co-construction of mutual understandings and is enhanced in midwifery continuity of care models (Dahlen, et al., 2023). In this paper, we unpack these similarities, demonstrating that constructivist grounded theory processes and midwifery woman-centred philosophy are complementary, and this characteristic could assist in addressing current maternity research gaps. The authors describe the benefits of constructivist grounded theory, not to exclude other methods, but to promote the value of considering such an approach to midwifery research, to expand our ways of knowing and bridge the current evidence-practice gaps (Catling-Paull et al., 2013; Crouchman et al., 2022; Fox et al., 2018; Prussing et al., 2023; Walker et al., 2018).

The authors would like to acknowledge the changing language with regard for inclusivity for trans, non-binary and gender diverse people – we are using both ‘women’ and ‘birthing people’ throughout this paper respecting that not all people who give birth identify as women. This includes the realisation that the ‘midwife-woman’ relationship may also be described as the ‘midwife-mother’ relationship; acknowledging that mothering can be done by people of any gender, and continues to be subjected to the same oppressive socially constructed structures that have historically oppressed women’s and birthing peoples bodies, voices and choice of care (Kirkham, 2010; Ruddick, 1995).

In this article, we outline the evolution of constructivist grounded theory methodology, its move away from positivist objective perspectives towards more subjective co-construction of meaning, and identify similarities in the midwifery profession, and therefore ‘midwife-mother’ relationship, face in medically led contexts. The focus is to demonstrate the synergies between the methodology and woman-centred care, and how this approach is important to facilitate new understandings that could improve maternal health outcomes.

The Evolution of Constructivist Grounded Theory Methodology

As researchers, it is important to understand that our social and political context influences the way we approach research (Charmaz, 2014; Rodwell, 1998). Researchers choose research questions, design methodologies and use theories guided by their values and interests (Guillemin & Gillam, 2004). The development of qualitative research approaches, such as grounded theory, acknowledges the importance of equality in health care, by identifying and raising less heard perspectives (Hall et al., 2012). Like earlier methodological pioneers of constructivist inquiry (Lincoln & Guba, 2016; Rodwell, 1998), constructivist grounded theory has continued to focus on the plight of disadvantaged peoples and the effects of structural inequities on them (Charmaz, 2017). Raising their perspectives through inductive analysis and responding to the data by modifying and fitting methodological strategies to explore further what the researcher discovers along the way and construct theory as a resolution (Charmaz, 2017).

These methodologies provide valuable tools for examining emerging areas of knowledge and focus on human experience, often with consideration of social norms, policy or politics, and cultural knowledge and practice (Hall et al., 2012; Rodwell, 1998; Steen & Roberts, 2011). The constructivist version differs from other versions of grounded theory, pulling from seminal theories within constructivist inquiry, locating the research in historical, social, and situational conditions, and is responsive to these factors within its processes which in turn influences its product (Charmaz, 2017; Lincoln, 2013; Rodwell, 1998). Knowledge and understanding is collated from experiences within the context of the social process under investigation, taking note of the social context of participants needs, issues, strengths and the resources necessary or available; additionally, that these are subject to adaption and change as the context and environment evolve (Lincoln et al., 2011; Charmaz, 2017).

Diverse approaches to grounded theory exist as a result of differing epistemological and ontological perspectives that have evolved since the methodology was first introduced by Glaser and Strauss in the 1960s (Charmaz, 1990; Higginbottom & Lauridsen, 2014; Mills et al., 2006). Grounded theory comprises three predominant schools; Glaswegian, Straussian (later co-developed with Juliet Corbin, 1990) and constructivist grounded theory (Charmaz, 2014). Glaser and Strauss developed their combined inductive approach to generating theory at a time when ‘positivist’ deductively tested hypotheses were the preferred scientific research method (Higginbottom & Lauridsen, 2014). Many contemporary scholars have since shifted away from the originally objectivist grounded theory perspective and endorsed a constructivist standpoint (Breckenridge et al., 2012; Charmaz, 1990; Mills et al., 2006) This move has many links and synergies to the seminal constructivist inquiry works of Rodwell (1998) and Lincoln (2013); embracing a relativist ontological view and epistemologically constructionist standpoint, which acknowledges the interactions between researcher and participants, and importantly how they construct meaning and influence the research process (Breckenridge et al., 2012; Charmaz, 1990; Mills et al., 2006; Rodwell, 1998). This is important, as constructivists suggest that meaning can be subject to change when it is found to be incomplete, malformed or faulty (e.g., discriminatory, oppressive, or nonliberatory) (Lincoln et al., 2011) which is more recently evident in the expansion of feminist, critical race, and queer theory. Constructivist grounded theory offers methods that can address social change by engaging in the discovery of contemporary research questions about justice and injustice, and allowing or initiating new research directions within its processes (Charmaz, 2017).

Constructivist grounded theory’s move away from positivism is synergistic with the current assertion by the midwifery profession to progress from the historical constraints of colonised childbirth within hospital settings (Dahlen, 2019; McKinnon et al., 2014), and acknowledging that midwifery researchers may be influenced by this history and be enculturated into hierarchical systems. It is widely recognised that midwives’ scope of practice is inhibited when working within the fragmented, industrial and medically orientated hospital systems (Newton et al., 2016; Prussing et al., 2023; Sandall, 1998; Yoshida & Sandall, 2013). Working in such institutions also gets in the way of the midwife-mother relationship, particularly when hospital policy or practice guidelines do not allow for individualised care or decision-making (Dahlen et al., 2023; Kirkham, 2010; McKinnon et al., 2014; Prussing et al., 2023). In turn, we also need to consider the way we work with participants within our research and the types of research being prioritised.

There is value in using a constructivist grounded theory approach, as opposed to the more traditional Glaswegian and Straussian approaches to research, as its processes emphasise the importance of relationship between the participant/s and the researcher and considers the emergent theory as a co-constructed shared meaning of the research phenomenon (Charmaz, 2014). This relationship and the resultant theory are acknowledged within their unique social context, in the same way that the importance of a woman or birthing person’s unique circumstances on their experience of childbearing is recognised in midwifery (Pairman & McAra-Couper, 2014).

Constructivist Grounded Theory Synergies that are Akin to the Woman-Centred Care Midwifery Philosophy

The philosophy of midwifery emphasizes the importance of the relationship developed between midwives and the people they care for, by giving them time to get to know each other, to develop a shared meaning through mutual understanding based on trust, shared control and responsibility (Freedman, 2016). Woman-centred care is widely accepted as care that strives to meet the woman’s physical, emotional, psychosocial, spiritual and cultural needs as defined by the woman/birthing person (Dahlen et al., 2023; International Confederation of Midwives, 2017). Midwifery values individual decision-making and self-determination, empowering the woman/birthing person to care for themselves and their family. These aspects are enhanced in a midwifery continuity of care relationship, in which a woman is cared for by one primary midwife throughout the childbearing journey. The relationship enables midwives to advocate for the woman/birthing person, which is central to the decision-making process allowing individuals to make optimal health care choices that meet their needs (Freedman et al., 2007; Rigg & Dahlen, 2021).

The origins of midwifery began with the tradition of women supporting one another around the time of childbirth. Midwives were part of a woman’s community, which afforded them an understanding of her life and circumstances (Page, 2014). From these roots, the meaning of the English word “midwife” has been defined as partnering “with woman” and this continues to underpin midwifery philosophy, work, and relationships (International Confederation of Midwives, 2017). The transition to hospital-based care, and away from homebirth, in first half of the 19th century in most middle to high income countries, saw the increasing industrialisation of birth and medicalised maternity care systems (Fahy, 2007; Tracy & Grigg, 2019). The medicalisation of childbirth has arguably diminished the relational partnership central to midwifery philosophy (Newnham et al., 2018; Rigg & Dahlen, 2021). These changes reflect the influence of hegemonic patriarchal and colonising structures into social institutions like medicine (English, 1976; Fahy, 2007; Sweetman, 2017; van der Waal, R., 2021). This influence not only led to the silencing of women’s and other marginalised voices (English, 1976; Fahy, 2007; Sweetman, 2017) but also to the subjugation of women’s and midwives’ knowledge (Newnham, 2014) and continues to hinder the development of alternative options of maternity care, such as midwifery continuity of care models (Prussing et al., 2023; Russell, 2018).

Today the hospital medical model prevails as the most prevalent option for birth in many countries. This is despite strong international research, which demonstrates that for women with a low risk pregnancy, midwifery-led continuity of care and homebirth provide a safe alternative to standard hospital care for both mother and baby, and, are associated with lower rates of obstetric intervention and improved satisfaction with care (De Jonge et al., 2019; Homer et al., 2020; Olsen & Clausen, 2023; Sandall et al., 2016; Sweet et al., 2022). Even in high-income countries with robust public health systems, such as Australia and England, only a limited number of women are able to access midwifery care outside of hospital medically led maternity services (Australian Institute of Health and Wellbeing, 2020; Coddington et al., 2020; Fox et al., 2018; Sandall et al., 2016). However, there is evidence of strong consumer demand for access to alternative maternity care options outside of hospitals (Catling-Paull et al., 2013; Fox et al., 2018; McKinnon et al., 2014).

In the last two decades, midwifery researchers have embraced quantitative research methodologies to demonstrate the safety of alternative options to hospital-based medically led maternity care. This has been useful in raising awareness of the benefits for midwifery care, its improved outcomes, and importantly gaining support of medical colleagues (Prussing et al., 2023). However, there is a critical need to look towards alternative research methods that identify the underlying structural barriers to the implementation of such research into clinical settings, so that women/birthing people and their families may benefit from these improved outcomes.

Essential to bridging this gap are transformative research approaches, that account for the underlying social and political-economic mechanisms impacting on the maternity service provision, and well-being of women/birthing people, newborns, families, and societies (Kennedy et al., 2018). Realist and critical research theorists suggest that the kinds of questions that funders and researchers have asked for decades are not suitable for the examination of complex maternal health systems (Chalmers, 1991; Kennedy et al., 2018; Russell, 2018). The authors argue research needs to explore the local social contexts and better understand the processes and social structures that will influence and support sustainable change, required to succeed with implementation of research into clinical practice (Kennedy et al., 2018; Russell, 2018).

Furthermore, it can be argued that the evidence-base from which women are being informed is limited, given the monopoly of positivist research design and the nature of dominant discourses such as medicine to reproduce knowledge that supports its perspective, and renounce competing kinds of knowledge (Kennedy et al., 2018; Newnham, 2014; Newnham et al., 2018; Newnham & Rothman, 2022). This knowledge base restricts women’s capacity to make fully informed choices or to access other forms of knowledge that might align with their needs and perspectives, including social and cultural identities (Kennedy et al., 2018; Newnham et al., 2018).

Constructivist grounded theory can broaden both the foundations and the practice of realist and critical inquiry. Although much qualitative research is inductive and emergent, constructivist grounded theory systematically prompts consistent inductive inquiry into the analytic process and incorporates methodological strategies to explore new analytical insights throughout the project (Charmaz, 2014, 2017).

Researchers need to explore the issues of what works, for whom, in which contexts, and pay attention to the short and longer-term outcomes that matter to consumers and stakeholders (Kennedy et al., 2018). It is evident that research implementation often reflects gendered, economic, colonising, and other power hierarchies that continue to privilege some voices and silence others (Kennedy et al., 2018; Kinney et al., 2016). Unless we understand the contexts in which research is being implemented or adapted, and who it is for, we risk continuing the status quo, the non-implementation of evidence (Russell, 2018), and perpetuate a ‘tinkering around the edges’ approach that does little to facilitate the urgent changes needed to solve the current crisis in maternity care, including increasing reports of birth trauma and obstetric violence (Keedle et al., 2022; Parliament NSW, 2024).

How Constructivist Grounded Theory can Break through the Barriers of Research Traditions

Constructivist grounded theory provides the opportunity to learn about the world being studied and to develop theories from within to better understand it (Charmaz, 2014; Glaser, 2002). It is therefore a useful methodology for those wanting to answer the call to start asking different questions, because it seeks to understand midwives’ and birthing people’s interactions and perspectives and explore the factors that influence their decisions and actions within their social contexts (Hall et al., 2012; Walker et al., 2018).

Based on a symbolic interactionist theoretical perspective, constructivist grounded theory, like many qualitative methodologies, acknowledges the shared experience between the researcher and the world of the participants being researched (Charmaz, 2014), accepting that the researcher may guide a process to generate theory, rather than validating a pre-existing theory (Breckenridge et al., 2012; Charmaz, 2014; Mills et al., 2006). To achieve this constructivist grounded theorists raise marginalised or otherwise silenced voices by staying true to participants’ own words (in-vivo words) using them as codes and categories, to ensure the analytic processes remain veracious to the participant’s perspective and ensuring this by using member checking of codes and ideas in follow up interviews (Charmaz, 2014).

Understanding the participants’ words and meanings is an integral part of constructivist grounded theory as these words and meanings guide the direction of the emerging theory (Charmaz, 2014). The use of gerunds (turning verbs into nouns) is another technique used to assist the researcher to consider the context from which they are constructing the codes. This process of modifying a verb (usually a substantive code) into a noun prompts the researcher to analyse actions and processes within the participant’s words. This encourages further exploration of the data, identifying contextual factors that are influencing the phenomenon under exploration, that are then constantly compared with previous data collected bringing to light any nuances or gaps (Charmaz, 2014).

Acknowledging Midwifery Researchers are Inherently Reflexive

Reflexivity is an important part of most qualitative methodologies and helps to maintain rigour, by positioning the researcher and acknowledging the role of subjectivity. Although, constructivist criteria for judging validity (or “reality”) is not so absolutist, but rather appreciates it from the social consensus of what is perceived as “real,” what is useful, and what has meaning (Lincoln et al., 2016; Rodwell, 1998). Constructivist grounded theory researchers’ rigorous scrutiny of the data, processes, and themselves throughout inquiry, allows for a critical stance to emerge and change depending on the participants, research goals, and self-reflection (Charmaz, 2017). Reflexivity encourages critical evaluation of the constructivist researchers’ thoughts and ideas that occur during research planning, data collection and analysis processes. In constructivist grounded theory, reflexivity also contributes to the attempt at building mutual understandings of both the researcher and the participants (Hall et al., 2012; Nugus, 2008).

The reflective skills possessed by midwives and other health workers may therefore help them as researchers. For example, midwives already use forms of reflective practice and are often able to quickly establish rapport. Mainey et al. (2023) describe how they drew on their clinical expertise in abortion care to effectively research this sensitive topic using constructivist grounded theory, acknowledging reflexive practice through self-awareness, theoretical journaling, discussion and debate with the research team and other experts in the field. The skills required for reflexive practice start with the ability to critically reflect on one’s own beliefs, biases and values, to give a deeper understanding and acceptance of the behaviours and actions of self and others.

An important aspect of reflexivity is about the relationship between the researcher and the researched. Many qualitative and critical methodologies recognise power relationships, aim to foster mutual trust, and take care not to take advantage (Charmaz, 2014; Guillemin & Gillam, 2004). These skills are apparent in developing the mother-midwife relationship which hone skills in active listening, attuning to subtle changes in body language, tone of voice or unusual behaviours that can prompt further investigation and insight into a woman’s needs (Schmied, 2023). These same skills are required when conducting research interviews and constructivist grounded theory opens the opportunity to explore such subtle responses further, within and between interviews (Charmaz, 2014). The ability to identify and explore these subtle participant behaviours facilitates the researcher to be guided by the participant during interview and enables them to respond. For example, noticing an emotional tone in a response may prompt the researcher to explore those feelings and understand the research topic on a much deeper level.

The capacity to be responsive to the participants’ stories, and their behaviours, is a valuable attribute embedded within constructivist grounded theory processes. Glaser’s (2002) dictum ‘All is data’ indicates that anything can be considered as a potential source of information (Charmaz, 2014). This gives the researcher an opportunity to explore further sources of understanding as the project unfolds, such as context driven influences, policies, social constructs, literature, additional participants and documents (Charmaz, 2014; Ginn & Benzies, 2020). Importantly, the decision to collect new data is prompted and informed by the emerging data collection and analytic processes (Charmaz, 2014). The research is opened up to meaningful exploration of alternative sources of information and allows for additional questions to be asked. An example of this is Ginn & Benzies (2020) including journal entries in their research exploring mentors’ experiences of mothers with vulnerabilities - a choice informed by their prior research, which determined that the mentor’s journals were a valuable source of data.

Theoretical sampling is another process of responsive inquiry, as once a tentative category has emerged, its properties are developed by seeking further information through additional participants, alternative sources of knowledge, events, revisiting data and reviewing literature that may show relevance during the analysis (Charmaz, 2014). Theoretical sensitivity is developed during the methodological process of memo-writing - a form of free writing allowing the researcher to note any reflections during data collection and analysis, encouraging investigation of concepts as they arise from the data. Prussing (2021) describe their decision to include additional interview questions about midwifery managers’ support for midwifery continuity models in response to new information introduced by participants during data collection. Memo writing highlighted midwifery managers’ emotions when describing how their workload hindered their ability to facilitate the implementation of new models of care (Prussing et al., 2023). This prompted follow up interviews with earlier participants, the data collected was developed through theoretical sensitivity and this process supported the construction of a new category (Prussing et al., 2023).

Constructivist grounded theory techniques prompt the researcher not only to identify the most common themes but to also question why these similarities are being identified, and to think about why not (what is left absent, or silent), this supports further exploration of the lived context and to consider what may be influencing the data (Charmaz, 2014). This capacity to seek/discover new forms of data opens opportunity for exploring other ways of knowing and new ways of thinking that go beyond the restrictions of more predetermined or recipe-like methodologies.

A Ground-Up Research Approach to Strengthen the Research Impact

Qualitative research has a lot to offer to our understanding of the world, including the translation (or not) of evidence into practice, and deserves our attention as a place of serious scholarly effort. Several recent Australian midwifery studies have used constructivist grounded theory as an approach to better understand what is required to overcome the barriers midwifery is currently facing to upscale and implement midwifery-led models of care (Coddington et al., 2020; Fox et al., 2018; Prussing et al., 2023). For Coddington (2018) a constructivist grounded theory research methodology allowed for examination of institutional and social practices amongst midwives providing publicly-funded homebirth. They demonstrated that for midwives accustomed to hospital settings, exposure to homebirth altered their understanding of physiological birth (Coddington et al., 2020). This transformation in perspective resulted in subsequent shifts in practice that dismantled power dynamics between women and their midwife/ caregivers, which is required in the prevention of unnecessary disturbances during labour (Coddington et al., 2020).

The transformational understandings gained by using a constructivist grounded theory approach are also demonstrated in a recent study, by lead Prussing et al. (2023), exploring factors that influenced the implementation of midwifery continuity models. This research found that women and midwives were the most influential factor; however, they underestimated this influence due to hospital experiences that made them feel devalued. The ability to continue collecting and analysing interview data resulted in further theory-building. Additional interview data encouraged unpacking the context driven barriers, identifying restrictive hospital practices that led midwives to lack confidence in their skills (Prussing et al., 2023). This prompted further exploration which uncovered potential solutions to these barriers, such as the crucial role project officers play in supporting change management, particularly for the midwifery workforce (Prussing et al., 2023). The constructed theory began to take shape as the substantive findings coalesced to form a process towards midwifery continuity of care implementation and theoretical sensitivity was further developed through the consideration of findings alongside current literature. These methods assisted with the construction of the theory, identifying that the partnership between women and midwives helped to build their confidence and knowledge, and together they were a strong political force that can influence maternity service redesign (Prussing et al., 2023). These findings reflect earlier midwifery theories highlighting the value of enabling midwife-mother partnerships and to consider the contextual influences on these relationships (Pairman & McAra-Couper, 2014).

Conclusion

Generations of new scholars influence the way research is understood and how it is applied. This paper argues the importance of midwifery researchers developing expertise in qualitative research methodologies and discusses the value of using constructivist grounded theory methods. This is especially relevant at a time when high level evidence, policies and professional associations, and most importantly women and birthing people, are advocating for increased access to relationship-based care, such as midwifery continuity of care models as well as greater emphasis on increased consumer involvement in the co-design of health services and research. Constructivist grounded theory encourages researchers to remain true to its participants and to raise awareness of their stories. This approach is useful in midwifery research, particularly with the over representation of medically focused research – that continues to perpetuate a culture of medically-led maternity care as the prevailing option. Constructivist grounded theory has the capacity within its process to ask different questions by embracing diverse ways of knowing and remain woman-centred in its exploration for improved understandings that raise the voices of the women/ birthing people and the midwives, at the centre of our practice.