Hearing different voices: Methodological pluralism in nursing education and research

This paper discusses the need for multi-cultural methodologies that develop knowledge about the maternity experience of migrant women themselves and that are attuned to women’s maternity related requirements under multi-cultural conditions. The birth of a child is one of the most culturally and spiritually significant events for women and their families, often validated through ritual. Studies show that cultures with supportive rituals for new mothers have lower rates of postnatal distress (PND) and that women in Western countries are at high risk of developing PND. The medical model assumes that because the physiology of childbirth is universal, all mothers experience the transition to parenthood in the same way, however, childbirth is conceptualised, structured and experienced differently according to culture. Like childbirth, migration is also a life changing experience, yet how the transition to parenthood occurs for mothers in a new country is an area where little research has been undertaken particularly in New Zealand. In this paper I will explore the literature around motherhood and migration with particular focus on the stereotypical views of migrant mothers as problematic and different rather than diverse and rich. I will challenge the positivist hegemony of previously completed research on migrant women by reflecting on my own experience as a researcher grounded in a broadly–based, pluralistic set of critical epistemologies that allowed me to uncover the issues and contexts that impacted on the experience of migrant women. It is my hope that by doing this I can contribute to changes in nursing education and research such that the voices of minority groups are heard and better health outcomes result. Introduction The birth of a child provides an apposite set of circumstances for understanding the appropriateness of various research methodologies to represent the experiences of different women. One of the most culturally and spiritually significant events for women (Khalaf & Callister, 1997), the transition of motherhood is often validated through ritual. Studies show that cultures that have supportive rituals for new mothers have lower rates of postnatal distress (PND) and that women in Western countries are at high risk of developing PND (Stern, 1983). It is often assumed that because the physiology of childbirth is universal that all mothers experience the transition to parenthood in the same way (Sawyer, 1999) but how childbirth is “conceptualised, structured and experienced” (Stewart & Jambunathan, 1996, p.319) varies from culture to culture. Moreover, little is known about how the transition to parenthood changes following migration for migrant mothers in New Zealand. This paper attempts to illustrate the need for further research relating to motherhood in a new country. It will present an argument for the use of alternative research frameworks that are able to more appropriately articulate the experiences of women from migrant communities. I will do this by briefly describing four discourses that have shaped knowledge development and representations of migrant women in the health care system. These are the biomedical discourse, ‘woman-centred’ discourse, migration discourse and the deficiency discourse. The impact of such discourses in guiding the responses of health providers to the needs of migrant mothers are then reviewed, which have been unwittingly exclusionary, pathologising and homogenising. The responses add weight to concerns that health services do not meet the needs of migrant mothers and alternative strategies are discussed that could counter the assimilationist, sexist and ethnocentric assumptions of prevailing discourses and create new discourses or discursive spaces. This paper points to the need for a new research agenda to inform practice in the maternity arena because of the inadequacy of the four prevailing discourses to bring about valid representations of minority women. This research agenda could incorporate methodological pluralism and reflexivity. Discourses are “socially and culturally produced patterns of language, which constitute power by constructing objects in particular ways” (Francis, 1999, p.383) and as such a person or group can be positioned as powerless within one discourse whilst positioning themselves as powerful in another. In the section that follows I will briefly explore the prevailing biomedical, midwifery, migration and deficiency discourses that impact on the representations of migrant women as passive, invisible, backward, pathological and emotional (Dossa, 2001; Jiwani, 2001). Reproduction is a key site for the regulation of women through two discourses derived from the disciplines of medicine and midwifery (Marshall & Woollett, 2000). The former biomedical discourse has been constructed as rational and scientific with more status than nursing or midwifery, which are associated with emotional qualities such as caring (Aitchison, 2000). According to Smith (1992), biomedical discourses position women as having limited agency and emphasise pathology, despite pregnancy being a major life event that most women go through without long-term difficulties. Kitzinger (1992) argues that medicalised discourses have transformed pregnancy into an objective observable process through technology where the woman bearing the child takes second place while the foetus is monitored and its growth recorded and supervised. According to Kitzinger, the woman is ritually dispossessed of her body during pregnancy as doctors take charge, asserting that they know more about her body than she can herself and that her body is a barrier to easy access to the foetus. Kitzinger concludes that the mother can risks no longer feeling like she has made her own unique baby. ‘Woman-centred’ discourses construct mothers as consumers, who take responsibility for themselves and their babies (Marshall & Woollett, 2000). A discussion with regard to the attitudes of midwives towards Asian women later in this chapter, however, reveals equally pathologising constructions of migrant women. ‘Other’ mothers Motherhood occurs in “specific historical contexts framed by intersecting structures of race, class and gender” (Collins, 1998, p.231), however Woollett and Nicholson (1998) argue that the dominant beliefs about parenthood come from white, middle class parents, researchers and policy makers rather than from poor families or ethnic minority communities. Women who do not fit within the dominant cultural subject positions are at risk of being pathologised as ‘other’ mothers on the basis of class, colour, ethnicity, race, sexual preference, education, employment or disability (Jolly, 1998). DeBeauvoir (1949) originally applied the term ‘othering’ to describe a process whereby people define who they are by contrasting self with others and historically this term was used regard to the relationships between men and women. Using the term more broadly, Aitchison (2000, p.135) defines ‘othering’ as being “characterised by dualisms, this process inevitably defines norms and deviants, centres and margins, cores and peripheries, the powerful and powerless”. The process of othering can occur in many contexts and usually refers to exclusion of a minority group by a dominant group on the basis of difference (Johnston, 1998). The creation of an ‘other’ necessitates the creation of a ‘same’, the latter being accorded greater status and power (Aitchison, 2000). The ‘other’ is seen as lowly and unsophisticated in contrast to the dominant group, whose members are seen as civilised and superior (Johnston, 1998). Ganguly (1995, p.1) argues that minority women have been conceptualised as others in two ways. The first is the “exotic other” of esoteric foods, culture, clothing, beliefs and practices and the second is the “oppressed other”, seen in the conception of a homogenous ‘third-world’ woman. The binary categories implicit in the process of ‘othering’ obscure the diversity that exists within groups, assuming homogeneity where it does not necessarily exist. Racialisation is an othering process that is implicit in the deficiency discourse (Torres, Mirron, & Inda, 1999), which posits that colonised people are lacking in qualities valued by the colonising society (Horsfall, 2001) and forms one of the main axes of subordination and domination (Bottomley, 1992). In this context, representations of minority women have reinforced prevailing stereotypes of migrant women as passive, backward and oppressed by their patriarchal cultures. The implications of these stereotypes for care delivery are discussed with more vigour later in this paper. Migration as masculine A fourth site of discourse that surrounds migrant women constructs them as passive appendages to men in the migration process, ignoring the complexities of women’s motives and their active role in the decision making process (Kofman, 1999; Leckie, 1989). Differences between male and female migrants have tended to involve simplistic comparisons rather than examining the complex interrelations involved (HondagneuSotelo, 1999). There has been a paucity of research undertaken on women’s experiences of migration and, prior to the mid-1970s, women were invisible in studies of international migration (Kofman, 1999). Leckie (1995) suggests that the dearth of literature on women migrants in New Zealand is due to gender biases in historical and social research and a profusion of generalisations and misinformation. However, Abusharaf (2001) suggests that this neglect is due in part to the historical view of women travelling alone as being unimaginable and a threat to family and community. In Europe, Kofman (1999, p.271) suggests, increasing attention is being paid to the experience of women migrants as a result of increasing interest in “women's position in society, the feminisation of the foreign population, the increasingly visible economic presence of immigrant women, and the production of knowledge by immigrant women about themselves.” In contrast with male migrants, whose main aim is to maximise economic gains, women have been seen as passive, migrating for emotional and personal reasons or as ‘dependents,’ moving in the roles of wife, mother or daughter of male migrants and only worthy of consideration in their role in the private sphere (Zlotnik, 1995). This role often encompasses the maintenance of identity of migrant communities as “cultural custodians” (Hondagneu-Sotelo, 1999, p.571) or fostering the integration of the family. Bottomley (1994) concurs, stating that early studies presumed that the roles of migrant women included continuing tradition and maintaining home life while remaining separate from the public sphere of work and politico-economic process. The positioning of migrant women within prevailing discourses has resulted in their construction as deficient, backward, passive and without agency (Arisaka, 2000). This section highlights how responses from health professionals toward migrant women are commonly based on two interrelated discourses, namely the pathologising discourse of the medical model and the deficiency discourse that is embedded within an ideology of assimilation that views adaptation as a one way process. Immigrants are expected to reject their own ways in order to fit into the host culture, whilst the dominant group’s ways remain unchanged. Implicit in these discourses is the requirement that those who enter the health setting must give up their power to be a ‘good patient’ since both are based on hierarchies that originate from the mechanism of ‘science’ and have the power to classify based on a modernist philosophical position of Western thought as universal (Arisaka, 2000; Nicholson, 1993). Jayasuriya (cited in Fuller, 1997) observes that society is comprised of heterogeneous groups that have the right to access health care services that meet their specific needs. However, it is more common for services to be constructed according to the needs of the dominant group based on an assumption of homogeneity with the occasional concession to cultural difference (Fuller, 1997). Barclay and Kent (1998) note the hegemony of the health system, observing that the needs of NESB mothers have been ignored by society and health professionals and suggesting that the care given to such women can be ritualised, professionally dominated and inappropriate. Responses from western workers to traditional postpartum practices range from “at best insensitivity and at worst derisory”(Barclay & Kent, 1998, p.6). Both Barclay and Kent (1998) and Fraktman (1998) contend that the focus on pathology and crisis within the health care system marginalises migrant mothers such that they are labelled in discriminatory ways that result in stereotyping and their differences are rendered into deficits. Fitzgerald et al. (1998) state, however, that the real debate is not whether distress exists but rather how it is expressed and categorised and, secondly, whether a particular explanatory model should be predominant and common human experiences and responses pathologised. According to Fitzgerald et al. (1998, p.21), the key issue is: “How can we best understand and respond to culturally influenced and contextualised experiences in meaningful and useful ways?” Stereotypes can provide a frame of reference for appropriate behaviour towards new people, however individuals can also be rendered invisible and stigmatised as a monolithic group by the imposition of a stereotype (Banister & Schreiber, 2001). This is because people “tend to be better informed about the dominant discourse(s) that pervade other cultures than the multiple positions that individuals in those cultures occupy; thus they tend to over-generalise or ‘stereotype’ the behaviours they see or hear about” (Ryan, 2001, p.198). Stereotypes are based on what is considered the norm or modus operandi of the dominant group (Fuller, 1997) and this norm is based on a hegemonic notion of ‘normal’ behaviour against which behaviour is compared. In Western culture ‘normal’ reproductive behaviour is socially constructed in much the same way as the enactment of the ‘sick role’ which typically requires cooperation and a belittling of discomfort (Goffman, 1969 cited in Bowler, 1993). The sick role and what is considered normal reproductive behaviour were significant aspects of a study by Bowler (1993) of Asian women’s experiences of health care by midwives in the United Kingdom. Bowler researched the types, effects and impact of stereotyping by observing and interviewing midwives and reviewing the literature. In this study, midwives used stereotypes to pitch their interactions and make assumptions about appropriate care and service delivery (as other health professionals do). Bowler’s (1993) findings revealed that midwives saw Asian women as demanding, having a low pain threshold, lacking in a maternal instinct, being difficult to communicate with, and lacking in compliance with preventative care and family planning. They were also seen as abusing services by having large families and having unrealistic expectations. Midwives did not acknowledge the positive characteristics of Asian women such as their abstention from smoking and alcohol. Bowler recommended midwives have education that challenges racist attitudes and the hegemony of the Western medical system. Similarly, a study by Day (1992, p.23) found that Asian women were frequently seen as “oppressed by their role as mothers, suffocated by domesticity and lacking independence.” These views are not limited to the maternal area, Wheeler (1994) asserts that the psychiatric literature also holds stereotypical views of minority users as problematic and different rather than diverse and rich. Labelling people rather than assessing their individual needs can be marginalising and discriminatory, particularly when labelling occurs within a deficit framework rather than on strengths and competencies as seen above. Many health professionals would be shocked to be called racist, yet Bowler’s (1993) study highlights the incongruencies prevalent in the behaviour of health professionals. In the study, midwives paradoxically held stereotypes of Asian women yet saw themselves as sympathetic toward them. The notion of institutionalised racism holds a possible explanation for this incongruence. This is where health workers see western health practises as superior and come to expect minority women to assimilate to these practices (Marshall, 1992). Ng’s (1995, p.133) concept of commonsense racism and sexism could also be useful for explaining the behaviour of the midwives, as it refers to “those unintentional and unconscious acts that result in the silencing, exclusion, subordination and exploitation of minority group members.” Another explanation for the behaviour is the notion of hegemony, as in the inability to see other ways of doing things. Hegemony occurs when dominant groups are able to gain control of culture with the consent of the majority of the population so that it appears natural and commonsensical (Cupples, 2001). Hegemony is not a monolithic process, however, and can be modified or contested by competing groups including subordinated groups. As a hegemonic device, the “deficiency discourse” (Dossa, 2001, p.40) individualises problems and ignores structural factors thus maintaining the dominance of whites in the racial hierarchy and minimising the impact of a racist society on migrant women. Ganguly (1995) on the other hand argues that framing barriers as structural, political and social, reinforces the stereotypes of migrant women as passive and traditional who lack skills or strengths. The ethnocentric and stereotyping behaviour of health professionals has also been called into question by Foss (1996) with regard to the care given by public health nurses. Foss accuses the research to date of being ‘Eurocentric’ and reductionist because of the focus on the mother. Foss argues that public health nurses base standards of what good parenting is (as defined by the dominant culture) on personal belief, interpretations and stereotypes based on professional experiences with other cultural groups. Foss recommends a new framework be developed to: assess ‘normal’ behaviours and cultural variations in immigrant populations; investigate immigration related health problems; and that nurses avoid judging parenting by the standards of the country of residence. Ethnocentrism is also evident in incidences of culture clash, where the beliefs and practices of women from ‘traditional societies’ clash with the Western medical model. A study by Nahas, Amasheh and Hillege of Middle Eastern women in Australia (1999) found that NESB women felt pressured by health professionals to change their beliefs and customs when what the women wanted to do was follow their traditional practices. One of many areas of culture clash is the notion of postpartum rest; in traditional societies, the family supports the woman to have a rest period in which to recuperate. In modern societies however, women are expected to be independent with mothercraft as soon as possible (Bowler, 1993). Bastien (1992) argues that in modern societies, postpartum rest is often seen as a sign of weakness and passivity whereas in other cultures it is sees as the expression of reverence for the transition and rite of passage that women have undergone. It is inevitable the ability to rest will be lost when a woman migrates to a modern society where it is not valued or there are no structures to support it and there is pressure to assimilate into that society. So far, the discussion has focused on the responses of health providers that marginalise migrant women. The responses reflect the ideology of assimilation, where adaptation is viewed as a one-way process. Assimilation demands that immigrants change to fit into the host culture by rejecting their own ways, with no corresponding demand for change on the part of the dominant group, therefore the dominant group’s ways remain the same (Fuller, 1997). A further area where the notion of assimilation is embedded is in terms of service development. In the main, migrant women have little input into services that are supposedly meant for them. Wheeler (1994) observed that minority users of mental health services have little control over resources that are thought to be necessary for their health, by providers, who are in the main white and do not reflect the population for whom they are caring. Wheeler suggests that this creates an unequal and oppressive relationship. To summarise, the challenges that face migrant women in the health system are related to the concepts of racism, assimilation, ethnocentrism and hegemony, which result in migrant women being stereotyped and pathologised, having their needs ignored and not having input into services. Need for a new research agenda Active intellectual work is needed to develop worldviews that differ from the prevailing worldviews of Western academia. For researchers of colour this means having to become epistemologically bi-cultural in order to survive (Scheurich & Young, 1997). The ‘outsider within’ position (Collins, 1990) position is developed by members of minority groups who are required to have fluency with practices of the dominant group in order to survive in that society but also have knowledge of their own contexts. This makes them able to relate to two sets of practices and in two contexts, although there might equally be a sense of being an outsider or of lacking fluency in both contexts (Narayan, 1992). The ‘outsider within’ position provides a useful stance for accommodating the range and acknowledging the limits of the multiple identities of the researcher and how the interplay of these identities can be used to interpret the experiences of participants and the research dynamics (Collins, 1990). The ‘outsider within’ position that Collins describes has the ability to be both inside and outside of what is being researched so as to understand both. This position provides a platform for critically examining the limits of dominant approaches when attempting to understand the experiences of marginalised groups. Such a tension can provide a means for new knowledge systems and insights to be created. Kaomea (2001) adds that the reconciling of this ‘outsider within’ tension might occur through the development of hybrid methodologies that would in my case speak to both Western and traditional ways of knowing. In this vein Bailey (1998) proposes two advantages of knowledge that is generated from ‘outsider within’ locations: Firstly, it creates a new focus on the experiences of marginalised groups that have been overlooked by other epistemological projects and; secondly, it provides knowledge for those in the centre to develop new understandings about their relationships with marginalised people from their own perspective. For the marginalised group, the outsider within position provides a means for capturing the complexities of their lives and for naming or voicing concerns that are taken for granted or hidden by a community (Smith, 1998). Being an ethnically diverse researcher with insider or emic status might not minimise or prevent the researcher colluding with the dominant group either, particularly if as WaitereAng (1998) cautions, the researcher is working within a Eurocentric paradigm, leading to a situation that Ladson-Billings (2000) terms ‘epistemic limbo’. Narayan (1992, p.266) reasons that, “there is rarely a dialectical synthesis that preserves all the advantages of both contexts and transcends all their problems.” Ladson-Billings (2000) concludes that the purpose of discussion of racialised discourses is to not just colour the academy, nor is it to dismiss the work of European or American scholars but to define the limits of prevailing standards of scholarship. This is a sentiment with which I agree and again consider that reflexivity can prove to be a useful strategy in advancing this agenda.