tended to presume that women's difficulties resulted primarily from their cultural difference, and not from any problems with the services. Phoenix. (1990) wrote ...
Sociology ofHealth & Illness VoL 18, No. 1, 1996, ISSN 0141-9889, pp 45-65
Pakistani women and maternity care: raising muted voices A.M. Bowes and T. Meehan Domokos Department of Applied Social Science, University of Stirling
Abstract The paper explores the potentiality of an empowering research strategy to raise the muted voices of Pakistani women, with particular reference to experiences of matemity care. It focuses on research carried out with Pakistani women in Glasgow in 1991. It is argued that issues of power negotiation need to be addressed at all stages of the research process, including the framing of research questions, during data collection through interviews, and in the analysis and presentation of results. Women's comments on maternity care were very varied, some being very satisfied, many not so. Three particular cases illustrate variation at the individual level, and muting interpretations are considered. In conclusion, it is suggested that an empowering research strategy may indeed raise muted voices, but that it can also give researchers more power. And the issue of the response to muted voices, a key aspect of the concept of muting, remains.
Introduction
The view of many health professionals is that nothing is wrong with the services provided. It is 'those people' with 'special diets', 'strange religious practices' or 'funny matemity habits' who have the problem. (Parsons et al. 1993:71) At that moment, I was mad . . . the pain was unbearable . . . they were shouting . . . why you never took the ante-natal classes . . . you should have, then there wouldn't be that much problem for you and for us as well. (Pakistani woman in Glasgow, recounting her experience of childbirth, 1994) This paper aims to explore some of the problems of, and prospects for, researchers hearing the views of Pakistani women, including those with © Blackwell Publishers Ltd/Editorial Board 1996. Published by Blackwell Publishers, 108 Cowley Road, Oxford OX4 UF, UK and 238 Main Street, Cambridge, MA 02142, USA.
46 A. M. Bowes and T. M. Domokos English language difficulties, with particular reference to matemity care. We will argue that, although working with women who have been systematically silenced is highly problematic, an appropriate research approach can enable such women to speak. To help conceptualise the processes which have led the voices of Pakistani women to be largely unheard, we will use Ardener's (1977) concept of muted groups, which emphasises the role of listening, as much as the role of speaking. Part of Ardener's argument refers to a need to develop new approaches to research: in recent years, feminist theorists have proposed ways of working which appear to promise to listen to muted groups, particularly women, by working with a notion of empowerment. Although, as Stevenson and Parsloe note, empowerment is often assumed automatically to be a good thing (1993:55), we will argue that its use in research requires more critical attention. Research aimed at ascertaining the views of women about maternity services has been predominantly quantitative, and there is evidence that such a method of approach, involving standardised, often self-completed, postal questionnaires, can fail adequately to collect the views of women of minority ethnic groups, including South Asian women. For example, Cartwright's (1987) widely quoted study, based on a postal questionnaire, achieved a response rate of only 42 per cent from 'mothers born in Asia' (p. 19), and Melia et al. (1991) compare their comparatively low response rate in an area with a high minority ethnic population to Cartwright's. Garcia's (1993) manual on ascertaining consumer's views of maternity services using OPCS research tools, which also stresses quantitative instruments, similarly raises the issue of low responses from minority ethnic groups. Such concern must be reinforced by suggestions that more disadvantaged mothers are the most dissatisfied with maternity care provision (Oakley 1991). As Pakistani women are concentrated in lower socio-economic groups, it is likely that they are unhappy with services. There have been some attempts to ascertain the views of South Asian women, including Pakistani women, on maternity services. Pearson (1986a) was critical of research which saw South Asian women's lack of attendance at antenatal clinics as a cultural problem, and in another paper (1986b) of cultural stereotyping in health education. Rocheron and Dickinson's (1990) evaluation of the Asian Mother and Baby Campaign revealed particular wants in relation to antenatal clinics and post-natal care, including appropriate food, longer dressing gowns, and prayer facilities, but Rocheron (1988) was critical of the Campaign itself, which tended to presume that women's difficulties resulted primarily from their cultural difference, and not from any problems with the services. Phoenix (1990) wrote an extended critique of the inappropriateness of many aspects of maternity services for all black women, including South Asian women. Parsons et al. (1993) are also critical of interpretations which stress women's characteristics, and fail to reflect on the nature of services: C Blackwell Publishers Ltd/Editorial Board IW6
Pakistani women and matemity care 47 they argue a need for the use of advocates who can aid women's access to care by putting forward their views, and providing support in their efforts to get them satisfied. Such people, they suggest, are more than mere interpreters, whose main job, it seems, has been to represent the views of services to the women. Bowler's (1993) important study showed very significant stereotyping of South Asian women by hospital midwives. Her work demonstrates the role of the services in silencing South Asian women particularly clearly: when they cried out in childbirth, their pain was dismissed by midwives as 'a fuss about nothing' (Bowler 1993:166). Work which has succeeded in raising South Asian women's views has tended to use more qualitative approaches to data gathering, such as interviewing and group discussions (Rocheron and Dickinson 1990), and observation and interviewing (Bowler 1993). Muting processes and empowering approaches
Ardener's (1977) useful conceptualisation of women as a 'muted group' stresses the domination of women's views of the world by the world views of men in many societies. He urges anthropologists to pay more attention to the altemative worlds of women in their studies, therefore allowing those muted groups to be heard. This is not a straightforward matter of raising previously silent voices, as part of the muting process involves failure to listen, at least as much as failure to voice. Muted groups can express their views, but they continue silent from the hearing point of dominant groups. We refer to muting as a 'process' to emphasise its dynamism and persistence, whilst recognising that it is also patterned: Ardener (1977) prefers the term 'structure'. Listening to muted groups, he argues, is likely to 'split apart the very framework in which they [women anthropologists] conduct their studies' (1977:15). He was suggesting that existing approaches to research refiected male points of view, and were not capable of discovering female ones. In his view, new methodologies were most likely to be developed by women. Ardener (1977) sees women as the most clearly muted group, but also argues that muting can occur wherever there are relationships of domination, including inter-ethnic domination: for example, referring to Okely's (1977) work, he notes that non-Gypsies remain ignorant of the world views of Gypsies, whilst assuming that they know them, and using stereotyping processes to confirm their certainty. Feminist sociologists in particular continue to argue for women's views of the world to be properly represented, and vigorously to defend feminist approaches to research which they consider to facilitate this process (see e.g. the recent debate of Hammersley 1992, Ramazanoglu 1992, Gelsthorpe 1992, Williams 1993, Hammersley 1994). Feminist methodology promises to be 'framework splitting', in that it claims to be able to © Blackwell Publishers Ltd/Editorial Board 1996
48 A. M. Bowes and T. M. Domokos represent women's views of the world. As Hammersley (1992) argues, whilst feminists have been most prominent in putting forward these arguments, tracing their descent from Oakley (1981) and Finch (1984), there has also been wider concern with issues of eliciting 'private accounts' (Cornwell 1984), and developing successful research strategies for doing so (Laslett and Rapoport 1975). In much of this work, the emphasis has been on gender, as was Ardener's (1977), in developing the idea of muting: but the concept is not tied to gender, and the category 'women' is not the only one which can be muted: already, we have noted the example of Gypsies, a muted minority ethnic group. In the 'race' field, Rhodes (1994) has recently argued for fuller, more critical discussion of parallel issues. Observing a concem among researchers in this field to refiect more faithfully the views of people in racialised categories, who are dominated and therefore muted, Rhodes (1994) notes that debates have focused on the issue of the social positioning of researchers, as compared with those they research. Thus, the issue of 'matching' researcher and researched in terms of categories of social position has been raised, and it has been argued that shared experience makes for 'better' research. Such arguments refiect Finch's (1981) view that women researchers can work better with women, because they share similar experiences. Rhodes (1994) argues, and we would concur, that insistence on matching of this kind carries the danger of marginalising certain types of research, making, for example, racism only a concern for racialised groups. The argument also carries an element of essentialism only women can understand women, only black people can understand black people - a view which calls the sociological enterprise into question by shifting the focus away from socially constructed categories. We will argue below, with Gelsthorpe (1993), that questions in this area remain open, and that there is not an 'ideal' position to which researchers can aspire. As is so often the case, we do the best we can in the circumstances, maintaining a reflexive, critical evaluation of those circumstances, and the way they influence our work. Rather than prescriptive solutions, we search for ways of recognising issues, and keeping them alive. A more focused concern with raising voices is to be found in the work of feminist researchers, such as Reinharz (1992), Lather (1986, 1988, 1991), and Opie (1992), who, from different points of view, put forward approaches characterised as 'empowering.' Reinharz (1992) sees a potentiality for many types of research strategy, including quantitative strategics, to be empowering; Lather (1986, 1988, 1991) writes of evolving and monitoring approaches to teaching which emancipate and empower. But there is debate about what empowerment means, and whether it is desirable. Opie's (1992) work, for example, adopts a critical perspective on empowerment, whilst still recognising its potential benefits. She is especially critical of Lather (1986, 1988) for what she sees as the imposition on the researched of a particular notion of emancipation. Similar dis© Blackwell Publishers Ltd/Editorial Board 1996
Pakistani women and maternity care 49 quiet, in reference to work in the field of third world development, is expressed by Long and Long (1992), who see 'empowerment' as implying power donated from outside to the powerless, who otherwise lack agency. Opie's and Long and Long's perspectives entail recognition of the negotiation of power in the research process (c.f. Strauss 1978), and the analytical linking of this power with wider social pattems of power distdbution. Since the basis of muting is domination, or the exercise of power, one way of raising voices may indeed be to shift the balance of power in the research process by devolving it to the researched. This is an issue for live debate, rather than an area for rules. Drawing on the expedence of research carried out in 1991, concemed with South Asian, and particularly Pakistani, women's health, we now examine a sedes of issues at several stages of the research process, which focus on the twin themes of listening to muted voices and attending to the negotiation of power. The first issue concerns standpoints, and refers particularly to power held by researchers associated with their social positioning. The second issue is that of formulating research questions, a process in which muted groups have not generally been involved. Thirdly, we focus on the process of interviewing, and explore some strategies for raising muted voices. Fourthly, issues of interview language are discussed in relation to the use of interpreters, and the changes in power relationships their presence can effect. Fifthly, we focus on listening to the muted voices, once they are raised. We use illustrations from our field material to demonstrate how the muted voices differ from various stereotypical expectations, and to present some of our interviewees' own challenges to processes of silencing. In conclusion, we stress that muting and the negotiation of power are themes which run through the entire research process, from formulating questions to writing up, and that empowerment of the researched may, in the end, make researchers more powerful.
Standpoints in research
Gelsthorpe (1993) refers to the stress on women's expedence as the basis for much recent feminist theory, and is cdtical of approaches which insist on expedence as a woman for participation in feminist work (Bhavnani 1993 argues similarly). She argues that whilst men cannot expedence life as women do, they can apprehend and recognise women's expedence, provided they are open to doing so. Part of the process of muting involves members of dominant groups channelling their perspectives into the use of stereotypes: in Gelsthorpe's (1993) view, members of dominating groups can open themselves to listen to muted groups, once they recognise muting, and question their presumptive, stereotyping perspectives. Rarely, she points out, does the researcher match the researched in every respect. There will always be some social ground which is not © Blackwell Publishers Ltd/Editorial Board 1996
50 A. M. Bowes and T. M. Domokos shared, which requires recognition in the collection, analysis and presentation of research data, but the existence of such territory does not invalidate the whole process of research. Gelsthorpe (1993) draws a parallel between issues attaching to men working with women and white researchers working with black people. There is a marked contrast here with the perspective adopted by Douglas, who argues that white women's accounts of black women's experience are inevitably flawed, because they rest on the assumption that shared experience of gender outweighs different experience of 'race' and class (1992:39). She beUeves that racism is the paramount influence on black women's experience, and that, because most white women do not experience racism, they cannot therefore understand black women's experience. We find it very difficult to grade experience in this way, and see this perspective as closing off possibilities, and ultimately as invalidating sociological work, in agreement with Gelsthorpe (1993:89) and Bhavnani (1993). Kazi (1986) and Ramazanoglu (1989, 1990) have also argued, though not using Ardener's (1977) terms, that representatives of the dominant, muting, white group can strip away the stereotypes which aid their dominance, and conduct research in ways which allow them to listen to muted voices. Put another way, researchers can adopt an anti-racist perspective, without having direct experience of racism. A considerable problem remains however, and this is where the issue of negotiation of power becomes relevant. There is no doubt that whiteness, in modern Britain, is tied to the particular pattern of racism by representing dominance, and therefore power. Even if she questions stereotypes, and tries to work in an anti-racist way, a white researcher represents power. She is also likely to have this reinforced by her class and professional status, and possibly by her age. The social identities of the researchers therefore remain a key issue. We discuss this matter and its implications in detail elsewhere (Bowes and Domokos 1995a). Here, we should note that neither of us shares ethnic identity with the women interviewed, and that we do not share experience of racism. Our social class differs from that of many of them, and there were occasions on which professional status affected our relationship with interviewees, in that they clearly perceived us as 'official'. We are both somewhat older than most of our interviewees, who were in their twenties and thirties, and Domokos, who conducted most of the fieldwork, has qualifications in nursing, midwifery and counselling: these factors were all capable of increasing the authority (domination) of the research, and the social distance between researcher and researched. These potential problems were tackled in two ways. First, a considerable degree of shared understanding with the women interviewed was aided by other aspects of shared identity, particularly motherhood, including experience of childbirth and maternity care. Secondly, there was a need to diminish some of the researcher's power, and the design and © Blackwell Publishers Ltd/Editorial Board 1996
Pakistani women and maternity care 51 procedure of the work attempted to accomplish this throughout the research process, as we will now discuss.
Raising health issues
The strength of racism in British society makes the issue of defining research questions especially sensitive. Where an exclusionary process is so strong, it is not unlikely that research questions can reinforce it. Thus, research questions have often been defined by an agenda which stereotypes South Asian culture as generating health problems, such as rickets caused by a diet deficient in vitamin D (e.g. Goel 1981), congenital malformations caused by consanguineous mardage (Parsons et al. 1993 and Ahmad 1994 review this work), lead poisoning caused by kinship dtuals (Pearson 1986b is cdtical of the anti-surma campaign), and dangerous traditional healers (c.f. Ahmad 1992). Such work, argue its critics, does not ask about the effectiveness or appropdateness of health services. Similarly, Roberts (1992), writing about women's health generally, has argued that in order to remedy the widespread tendency for health researchers and professionals to tell people what they need, attention should be given to finding ways for health service consumers to represent their own views of priodty concems. Such arguments are paralleled in health services. For example, in attempts to improve maternity services, link workers were appointed as part of the Asian Mother and Baby Campaign (AMBC). Their job was to make the task of the service providers easier, by translating information, accompanying women on antenatal visits and so on (Rocheron 1988). Thus the link workers, cdtics have argued (Rocheron 1988, Phoenix 1990, Parsons et al. 1993), could be seen as symptomatic of a problem with the AMBC, which had tended to determine in advance what Asian mothers' problems were, rather than asking the women themselves. Parsons et al. (1993) argue that there is an important difference between link workers, who tend to represent the services, and advocates, who can represent women's views. It seems to us that the advocacy approach in practice has limited parallels with Roberts' (1992) call for input from 'the researched' in the formulation of research questions. Our research aimed to establish women's own health concems, including those related to service provision. The substantive findings of the project have been reported in other papers (e.g. Bowes and Domokos 1993, 1995b). Nineteen Glaswegian Pakistani Muslim women (and one Libyan) were interviewed. They were contacted through an existing network of relationships (Bowes 1987, Wardhaugh 1990). The interviewees were generally typical of local Pakistani women in age, socioeconomic group, housing and life cycle stage, according to earlier research (Bowes et al. 1990). We saw personal contacts as one way of maximising women's © Blackwell Publishers Ud/Editorial Board 1996
52 A. M. Bowes and T. M. Domokos confidence to speak, trying to minimise barriers of confidence between interviewer and interviewee. Semi-structured interviews, about one hour long, were carried out by Domokos, either in women's homes or in a community venue of their choice. The main areas of interest were women's ideas about good health, assessments of their own and their families' health, experiences of health services, and suggestions for improvements in health services. Further data were also gathered at three South Asian women's group meetings which Domokos attended, and from a Women's Health Day we organised. All the interviewees, and other local women, were invited to participate; about twenty women attended, and we spent the moming discussing our findings, and receiving women's feedback. A relaxation session followed lunch. Finally we reviewed a range of health education materials, produced by health promoters specifically for South Asian women. The stress throughout was on ascertaining women's own views, and the research instrument, the process of contacting interviewees, and the interviews themselves were all designed with this aim in view. The interviewing process
The research instrument aimed to depart from stereotypes by eliminating, as far as possible, the predefinition of answers. In general, it tended to quieten down the researcher's voice and to diminish her potentially authoritative position. Interviews were guided by a schedule of previously prepared topics which we had listed as relevant to health and health service use: there was no preset list of questions. We began simply by asking 'How would you describe a person who was really healthy?' Topics were then covered in the order that they were raised by the women. Most of the interviews covered most of the topics, but in varying order of priorities and depth of significance to the women's own views. Coverage of topics was monitored by subsequent scrutiny of the transcripts. Very little questioning was used. The process involved careful listening, making supportive comments which communicated understanding and respect for the women's exjjeriences. The personal introductions meant that initial trust was established, and this was built up further during the interviewing process, as we will discuss. One result of the nature and use of the instrument was that the infiuence of women and their circumstances on the shape of the interviews was often considerable. For example, on one occasion, the woman was in severe pain and it was inappropriate to continue the interview beyond half an hour. At other times, it was impossible to leave when the pre-arranged time period was up. The researcher had acquired rich data, and felt obliged to offer something in return, such as support, or infor© Blackwell Publishers Ltd/Editorial Board 1996
Pakistani women and matemity care 53 mation about health, the health services, or simple friendship and conversation about shared experience like motherhood, husbands, extended family networks, work responsibilities. From our point of view, the interview remained an instrumental, datagathering process (see Edwards 1990). But it was clear that some women saw the occasion in other ways and used it differently. For example, one woman who had initially used her adult daughter to interpret, asked if Domokos would retum for a second visit. Domokos agreed, but on the second occasion, the daughter was busy. Although she was still willing to interpret, her mother did not seem to need her. She communicated her grief and pain at losing both of her daughters through marriage, her loneliness and separation from her family in Pakistan whom she could not afford to visit, and her bitter disappointment with her unhappy marriage. Using very few English words, she relayed her feelings by pointing to photographs, using sign and body language, and facial expressions. It did not seem to matter to her that Domokos did not understand the details of the words she was using. The potentialities for women to shape and use the interviews indicate a degree of researcher disempowerment built into the process. It is important to stress that this disempowerment was designed into the work, and controlled. It did not therefore result purely from natural shared concerns (stressed by Finch 1984) or partnership (Oakley 1981) between women. Despite the women's influence, the interview was ultimately controlled by the interviewer, who set its boundaries: for example, in planning the work, we decided we would not distress women by pushing them to talk about topics they preferred not to discuss. From an instrumental point of view, there were costs and benefits to us in this approach. The costs were that there were some areas in which our data were less rich. The benefits were that women readily talked, in depth, when they felt comfortable, and the data in those areas were very rich. 'Empowerment' at this stage of the project involved the interviewees having more control over the interview, but it is important to note that this empowering research strategy did not cause power to disappear; it was negotiated in a different way. To develop this point further, it is useful to examine how a more structured research instrument can affect interviews. If the researcher asks a direct question, especially one that has been pre-formulated outside the context of the interview, this can involve subtle exercise of power. She can signal superiority, that she has prior knowledge and expertise beyond the cognisance of the interviewee, which entitles her to feel that her insights are greater, and her views more worthy, than those of the interviewee. She shows that she is more familiar with the interview situation and is in overall command. Such an approach seems capable of inducing several unhelpful reactions in the interviewee which the researcher may misinterpret or of © BlackweU Publishers Ltd/Editorial Board 1996
54 A. M. Bowes and T. M. Domokos which she may even be unaware. The interviewee may want to make a good impression. This will tempt her to offer a 'correct answer', for example, one which conforms to a medical model, or an answer which will make the interviewer leave, satisfied but deluded (see Okely 1984), or whatever she thinks will most impress the researcher. Or the interviewee may feel inferior and inhibited in her thinking, offering 'don't know' or superficial answers. Or she may choose simply to withhold information. She may hide these negative feelings beneath a veneer of good manners, especially if she is aware of class differences between herself and the researcher. All such reactions involve interviewees infiuencing the interview to the researcher's detriment, therefore perhaps exercising power. But it is still the case that the researcher's approach has silenced the interviewee's ability to voice her views. Power negotiation of this kind can therefore have negative effects from the point of view of a researcher looking for muted views. Such mute responses have been described as putting on a 'best face' (Laslett and Rapoport 1975), reproducing the 'culturally normative pattem', or sticking to the relative security offered by 'public accounts,' as opposed to the more sensitive 'private accounts' (Cornwell 1984). If the interview is understood as a social process, it is clear that, depending on the type of relationship set up, interviewees will respond in ways they consider socially appropriate. If a researcher is interested in muted accounts, she/he has to attempt to create the kind of relationship in which these will be given. This is not a purely personal matter, as 'building rapport' might be, but operates within a broader, social structural context; hence the relevance of issues of power. Researchers need good reasons for using strategies which persuade people to say things they might otherwise prefer to remain unsaid. Edwards' (1990) work is important here for stressing the instrumental purpose of empowering research strategies - to improve the data. Ribbens (1989) further suggests that researchers who collect people's more private views have more power themselves. Opie's (1992) important discussion of the need to present different and competing accounts in reporting research findings needs, therefore, to be extended back into the interviewing process itself, if the process is indeed aimed at ascertaining the interviewee's view of the world. The interviewer has the power to silence which, as we have noted, is easily exercised through intrusive questioning. Laslett and Rapoport (1975) also call attention to this potentiality, and write of the need for control over the interview to be shared by interviewer and interviewee. They comment that relinquishing control may be an unfamiliar and perhaps disturbing experience for an interviewer. In our experience, such interviews are unexpected by interviewees, many of whom are surprised to be asked for their own views.
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Pakistani women and maternity care 55 Interview language
In discussions of South Asian women's access to matemity services, language is a prominent issue (e.g. Rocheron and Dickinson 1990, Parsons and Day 1992, Richardson et al. 1994), and there are calls for services to provide better interpreting, through translated health education materials, link workers or advocates. Language is, of course, also an issue in research which attempts to hear muted voices. Using the preferred language of the women with whom we worked would entail using English, or Urdu, or Pakistani Punjabi, or perhaps Glaswegian Punjabi, which mixes Punjabi with Glaswegian English, and often switches between the two. Which language a woman preferred to use was not, we found, a clear-cut issue; the fiexible interviewing technique was important for allowing the issue to be negotiated, and the most effective possible form of communication used. Since Domokos does not speak Punjabi, and most of the women spoke English, this was the language generally used dudng interviews and group discussions. However, an interpreter was present at each group meeting, and accompanied the researcher for five interviews where the woman requested such assistance. In each case the interpreter was known to and approved by the interviewee. The issues of power and control in the interviews were particularly interesting when an interpreter participated. Observation of the interaction between the interviewee and the interpreter revealed some advantages for interviewees in the use of an interpreter. Women who could not speak English appeared potentially to be the most disempowered, isolated, and lacking in confidence. For them, the processes of muting were at their strongest. Whilst it would undoubtedly have been an added advantage for her to have understood Punjabi, Domokos felt that the presence of a known and trusted interpreter was beneficial for the women. It affected the balance of power in the interviews. Although present, Domokos felt initially excluded from the discussion between interviewee and interpreter. The interviewee had the opportunity to 'test' her ideas on the interpreter, who played a facilitating, enabling role, encouraging the woman to express herself in a way which shielded her from the potentially disabling effects of the researcher's presence. The role of interpreter in these interviews was designed to be akin to that of the health advocates previously mentioned, in that our interpreters were very much involved in the interviews, and helped the women express their views. They were much more than translators, or, possibly, link workers. However, the role of these interpreters was restricted, in that they were present only at the interview and were not involved in other parts of the work. In particular this left no opportunity for the interpreters, who had played such a key role in the interview, to bring O BlackweU Publishers Ltd/Editorial Board 1996
56 A. M. Bowes and T. M. Domokos their experience to the process of analysis. A strategy which involved an interpreter following her work through to this stage of the project is described by Currer (1986): it allowed sensitivity to the interviewee to be maintained more fully, and for the process of translation to be kept to the fore. A bilingual researcher would need also to refiect in this way on translated interviews. Experiences of maternity care: analysing data and reporting results
Muting, as we have argued, can be reproduced in the definition of research questions and by approaches to data collection. It can also be carried into analysis. As Bryman and Burgess (1994) note, whilst qualitative researchers have become increasingly explicit and refiexive about their methods of data collection, there has, unfortunately, been rather little published refiection on methods of analysis. Brannen, however, notes the vulnerability of interviewees to writing up, especially if they are members of subordinate groups (1988:561), and Scott argues . . . the analysis is usually unilateral, and the researcher is placed in the powerful position of translator or presenter of other women's lives, searching the transcripts for quotable quotes to aid in the development of an argument (1985:80). Such a procedure would undoubtedly mute. To approach the analysis, we indexed and sorted the transcripts, using a computer as a tool. The computer helped us manipulate tbe transcripts into forms which allowed us systematically to review, for example, all the women's comments on antenatal care, all the questions we asked about it, all the ways in which the interviewer encouraged women to talk. But the computer could not, of course, interpret the data (see Fischer 1994). The indexing grew out of what the women said, and was developed through repeated reading and discussion of the transcripts. In attaching indexing, we endeavoured to include as much relevant context for each statement as was practical, and allowed for statements with several referents to be indexed several times. The systematic review of the interviews and the inclusion of all the women's statements in our sorted files ensured that no one woman's contribution on any topic was lost, and that we thus avoided the temptation to 'remember' only those comments which confirmed our preconceptions (see Opie 1992). In working on our interpretation, we used the sorted files, and also referred frequently back to the full transcripts. As we did so, we tried to maintain tbe same approach we had used in the interviews, allowing the interviewees to speak, and listening to what they said. Maternity care was one of the most sensitive topics in the interviews, conforming to one of Renzetti and Lee's areas of sensitivity, in that it © Biackweil Publishers l.td/Editorial Board 1996
Pakistani women and matemity care 57 was a 'deeply personal experience' (1993:6). It was covered in all the interviews except one, with a woman who had no children. As a 'sensitive' issue, it was difficult to talk about, many women were very hesitant to express their views, and in many ways, we were disappointed with the data. We had approached the interviews with the aim of allowing women to speak: we also allowed women not to speak if they preferred, if, for example, a subject upset them. When women did speak about childbirth, it became clear that many of them had suffered traumatic expedences, and we respected their choice not to recall these in detail. In the absence of a back-up counselling service, it would have been wrong to press them (see Kitzinger 1992). Furthermore, Bowler's (1993) work demonstrates, as we have noted, the very strong silencing processes experienced by South Asian women in childbirth. In view of these points, we must caution against assuming that women's reluctance to speak in detail was related to culturally-based modesty; trauma, fear and pain were much stronger themes. From these women's point of view, their cries in labour were cries of pain, certainly not the stereotypical 'fuss about nothing' (Bowler 1993:166). There was a need to strike a balance between raising muted voices, and respecting women's silence. Our difficulties compare with Bergen's (1993), in her work on marital rape, in which she, too, faced problems talking to people about very personal experiences. Whilst considering the possibility that researchers should not persuade people to talk, she argues that the importance of raising their views can justify a risk of harm to respondents. Our decision was to minimise this risk, at the price of some depth and detail of data. Nevertheless, we did collect some valuable data, which reflect views that are not generally heard, and which therefore challenge muting. The comments that we now report reflect the women's own emphases and choices of topic. The material suggests that women's views on hospital practice, when ascertained through sensitive research, differ markedly from professional views of appropriate post-natal care. There was wide experience of negative staff attitudes, including stereotyping. Many interviewees were reluctant to criticise any aspects of the service they had received, and found it difficult to express their preferences. On antenatal care, our interviewees' comments reflected the concems of many other women, the difficulties of travelling on public transport, and of long waiting periods in the clinics, especially with small children in tow. Many had not attended antenatal classes. One woman described how sorry she was during labour that she had not attended the classes: her midwife was very punitive towards her because she had not attended, and in fact refused her pain relief because she had not been taught 'how to breathe,' or how to use the gas (see Bowler 1993). For her, the experience of childbirth had indeed been traumatic. These views challenge stereotypes: women were not attending antenatal classes, because they © Blackwell Publishers Ltd/Editorial Board 1996
58 A. M. Bowes and T. M. Domokos found them impossibly inconvenient, not because of an altemative culturally-determined approach to birth. And they recognised the potential benefits of the classes. After their baby's birth, women appreciated midwives taking their babies away from them at night, and long hospital stays post delivery. These wishes are against the grain of current policies of 'rooming in' and early discharge, and differ from those of health professionals and childbirth campaigners (e.g. Kitzinger 1989, Stanway and Stanway 1984). They are not the kinds of choices promoted in recent policy documents (e.g. House of Commons Health Committee (1992)) and can serve as examples of women's preferences which are likely to be muted, by a failure to listen. There were frequent comments on staff attitudes. Negative attitudes were usually, though not always, perceived as racist. The degree of racism expedenced varied widely as did the effects of racism on individual women. An articulate woman who usually wore westem clothes explained why she wore the shalwar chameez (Punjabi dress) to the antenatal clinic: I will wear these clothes, and open my mouth later on to shock peopleyou know, shock white people, because they think this is an idiot sitting there wearing these clothes. Her experiences strongly suggest that, even if women did manage to attend classes, they were likely to expedence stereotyping there. In her comments, this woman reflected experiences of racism which were common to many of the women we interviewed, whilst expressed in many different ways. Hospital food was criticised by almost all the women, especially the lack of halal or vegetarian alternatives, and was linked to expedence of staff assumptions about stereotypical extended families: She [the nurse] was saying you know why don't you phone your husband to bring something for yourself or from your family. I said I've no family here . . . it's hard enough for him to feed himself, he never cooked. [Husband]. This was another very common expedence of racism. There were some positive comments on staff: I used to write my mum, 'they're angels over here, and they don't consider if you're a black or a white person.' This woman's account linked her more recent expedence of racism in the health service to cuts in expenditure. On several occasions Domokos noted that women were reluctant to say anything which could be interpreted as a complaint. Women seemed genuinely appreciative of the services available, to the extent that they did not feel that they had the right to hold, let alone state, their individual preferences. Thus problems with racism tended to emerge gradually, as © Blackwell Publishers Lid/Editorial Board 1996
Pakistani women and matemity care 59 the interviews unfolded. This emphasises the importance of looking at the whole of interviews, and their overall shape, which reveals the way more sensitive areas are covered (cf Brannen 1988). Our essentially ethnographic research design also offered the opportunity to produce holistic accounts of any one participant's story. Thus it helped us to give weight to the exceptional individual, as well as to the consistent viewpoints of the majority. The considerable variation in women's voices, once heard, quickly became clear. For example, considering the issue of language, three particular interviews help build a picture of the range of experience among this small group of women. The first woman did not speak any English at all, and was totally dependent on her husband who had recently had a heart attack. The realisation that she might be left widowed, unable to communicate in an alien and sometimes hostile society was a terrifying prospect. For her, language problems seemed paramount, and the local South Asian women's group with whom she was then in contact, was a lifeline. The second case is that of a young eighteen-year-old mother who had lived in Scotland since babyhood. Educated here, she would seem to have what the first woman lacked, language. However, Domokos bad considerable difficulty communicating with her. She had been married when she was just sixteen, and she was not allowed to leave the house. She had limited vocabulary, was very depressed, and was reduced to silence whenever her relatives entered the room. In a labour ward, fearful, depressed and lacking confidence, she would be little better off than the first woman. On the surface, the third woman appeared confident and articulate, and was in full-time employment. Yet she felt that she was denied access to good health. She spent much of her time in the company of white people, and, for her, racism was paramount. She gave a rich account of the processes of exclusion in her social and professional world, and of the devastating effects these can have on health and wellbeing. On child rearing practices, she stated . . . people will think worse of me than they'll think of you because at the end of the day it's down to my culture, it's down to your choice. People say that you're not integrating . . . so you kind of stand out from the crowd which you don't want to do either, it's like a game: if you don't play their game their way, then either you lose, or you're labelled a troublemaker. She began this interview angrily, aggressively, and determined to control it. She perceived a qualitative study as a forum for venting many negative experiences at length, and in a depth which she could not have achieved in response to a quantitative survey approach. As she unfolded her account, her desire for control seemed to weaken. While maintaining an © Blackwell Publishers Ltd/Editorial Board 1996
60 A. M. Bowes and T. M. Domokos attack on both interpersonal and institutional racism, she also described severe problems she had encountered due to her own family's complete rejection of her, because of her non-traditional lifestyle. The three accounts illustrate muting processes in different ways. The first woman could not speak the language of the services, and the services had no facilities to help her communicate. It was fortunate indeed that she had come into contact with the women's group, which had helped many women with problems of service access (Wardhaugh 1991). It is important to note that this woman would be the most likely to have her problems blamed on herself, particularly her lack of English, and would be the least likely to be heard. The second woman might induce sympathy for the individual at the expense of promoting a negative cultural stereotype. Early results from our current study of white women, however, already challenge the assumption that South Asian women's needs are particularly 'special'. Where South Asian women themselves express the desire to be treated differently, e.g. in antenatal classes, or women's health groups specifically for South Asian women, this could simply refiect their sensitivity towards being patronised, judged, or discriminated against in a variety of ways, in mainstream group settings. Their choices are stimulated by racism rather than cultural preferences. Muting is the strongest factor. The third woman had no problems expressing herself: as she explained, her difficulty was that she was silenced by others who did not listen, preferring to stereotype her. Quiet, she was a 'typical Asian woman', speaking, she was a trouble maker, the 'loser' in the game, whose rules had been made by others. She brings home very forcefully the point that there is little incentive for the muted group to speak, and, indeed that their voices can reinforce the silencing process as they are used to confirm stereotypes, here, racist and gender stereotypes.
Conclusion
We aimed to explore the potentiality of an empowering research strategy to raise the muted voices of Pakistani women on maternity services. The need for 'framework sphtting' was raised by Ardener (1977), during this development of the concept of muted group, and feminist researchers had suggested empowering strategies in more recent years. We argued that these strategies merited critical attention because they had not generally dealt with issues of 'race', had frequently been seen as necessarily 'good', and also because researchers had tended not to examine the negotiation of power in the research process. Our discussion centred on these issues through the whole research process, from raising research questions, through data collection, analysis and writing up. In discussing the social positioning of researchers, we © Blackwell Publishers Ltd/Editorial Board 1996
Pakistani women and matemity care 61 argued that, whilst white researchers could adopt an anti-racist approach to their work, thus challenging stereotyping and other processes of exclusion, if the project aimed to raise muted voices, it remained necessary to look in detail at the research strategy itself, and to ensure that it challenged the potential power of researchers deriving from their social standpoint. In earlier work, research questions had been influenced by exclusionary preconceptions of culture, and we therefore set out to create interviews in which women could raise their own concems. The interview procedure aimed to quieten the interviewer, and to ensure that interviewees had more than customary control over the process; the negotiation of power was evident. The boundaries of the process, however, still remained under the researcher's control: Domokos, for example, prevented the interviews from becoming counselling, using her training in this area. And within these boundaries, we were creating conditions for women to express themselves in certain ways: we were attempting to prevent, for example, the presentation of the 'best face', and trying to encourage the expression of the muted views. Using interpreters emphasised these issues more strongly: they made our control more difficult, as interpreters become involved in women's negotiation of their expression of views. The general principles of challenging stereotypes, and attending to power negotiation were maintained through the processes of analysis and writing up. In reviewing comments on maternity care which revealed muting processes at work, we illustrated some pattems across the women's accounts, and also some marked variation between them. We suggested how easy it would be, at this stage in a project, to resurrect stereotypes, but illustrated, looking at the three cases, the considerable range of experiences and views represented in our work. The central feature of the 'framework splitting' approach we have used is that it attempts to eradicate processes of stereotyping, and hears the voices which then speak: negotiation of power at all stages in the research process, rather than seemingly straightforward empowerment of 'the researched', appears to be the mechanism allowing these events to occur. Although our account has been framed by a focus on qualitative work, and we were, indeed, critical of some quantitative studies, we would argue, with Reinharz (1992), that a critical application of different kinds of research tools should have similar potential. Whatever research tools are used however, the notion of 'empowering' research approaches now appears somewhat more complex: the researched may be empowered to speak, but the researcher finds herself faced with greater responsibility (or power), in that she has now faithfully to represent the muted views to those who prefer not to hear them. Stacey argues, referring to ethnographic work, 'the greater the intimacy, the apparent mutuality of the researcher/researched relationship, the greater the danger' (1988:24). Muted voices are indeed raised, but © Blackwell Publishers Ltd/Editorial Board 1996
62 A. M. Bowes and T. M. Domokos become research data, more valuable material in the hands of researchers. Ribbens criticises notions such as collaborative research, and refiects I increasingly come to believe that this is the greatest power sociologists may have - to define other people's realities for them and for others (1989:589). The last woman we quoted faces the issue of what is to happen once tbe muted voices are raised: in her view, the outlook was pessimistic, in that the stereotyping process would then devalue the accounts as 'troublemaking'. It is very likely, as we noted, that muted voices will challenge and compete with dominant ones, and thus that South Asian women will not say what they are expected (stereotypically) to say, or what people would like to hear: they are very likely to say the wrong thing. Address for correspondence: A.M. Bowes and T.M. Domokos, Department of Applied Social Science, University of Stirling, Stirling, FK9 4LA, Scotland.
Acknowledgement The research was funded by the Chief Scientist Office, Scottish Office, Edinburgh. An early version of this paper was presented to a meeting on assessing the needs and experiences of women using the maternity services who do not speak or write English, organised by the National Perinatal Epidemiology Unit, 12 May 1994. We thank the participants at the meeting for their comments.
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