Liminal Phase

The liminal phase is the transitioning phase in the rite of passage, whereby people do not ascribe themselves to their old identities and behaviours but have not yet been completely incorporated into their community and their new identity. Pregnancy in general is seen as being in a liminal state (Davis-Floyd, 2003), whereby women are in- between being a woman and being a mother. Or in the case of the women in this

ethnography they are already a mother and are pregnant again. The women participating in the intervention are in a liminal state, in that they have a decision to make as to whether they want to try for a VBAC or have a repeat CS.

Added to this, the OptiBIRTH intervention can also be seen to be going through the liminal phase during its time in the antenatal clinic. This liminal phase occurred in the early months of the main intervention until September 2014. It is between the states of being introduced to the clinic staff and women but at the same time it has not yet been considered to be a part of the clinic and the acts that are conducted in the clinic, such as asking the women if they smoke or if they have noticed any changes in the foetal movements. At the start of the intervention (April 2014), healthcare professionals were slow to take on the study and the recruitment process being slow, with many of the midwives in the clinic relying on me or the MOL to remind them of OptiBIRTH. This might have been due to the business of the clinic setting and staff being under workload

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pressure. It might also have been due to staff not knowing enough about the study at this time so as to comfortably talk to the women about the intervention, what it aimed to achieve and by what means it would do so. At this time, OptiBIRTH was in an in- between stage in the clinic; depending on the midwife recruiting, it was either forgotten about or the midwife was able to give the eligible woman a full description of the intervention and to talk to her about VBAC and fill in the screening chart. I give an example of this from my fieldnotes:

As [Midwife 1] is leaving the clinic she turns to me and tells me that she booked a woman in today that had a previous CS. She then goes to the trolley and shows me the woman‟s chart so that I know she is eligible for the intervention when she comes into the clinic. [Midwife 1] did not mention whether she talked to the woman about

OptiBIRTH or not so I have no idea what she knows. I have not really seen [Midwife 1] screen women in the clinic and she never really talks to me so I don‟t know how much she knows or thinks about the intervention. [Midwife 2] then comments that „everything is flying today!” in terms of the charts being handled and it certainly is! [Midwife 2] then turns to [Midwife 1] and tells her that the trial has had its first birth. She is really excited and happy about it and I smile because the woman had a VBAC. It‟s good news. [Midwife 1] says “oh great!‟ and seems to be happy about it although she is always one of those people that always looks happy. But throughout this whole morning and recruiting without [Midwife 2] or myself being there as the reminder, which I don‟t think is a good thing, I believe that the intervention would be forgotten about. It is only with the midwives that really believe in the intervention that are trying to screen the women and I think they are the ones to truly let the intervention into the clinic and pave the way for other midwives in the clinic when myself and [MOL] are not there. (Field-notes, July 2014)

This field-note shows the „in-between‟ stage of the intervention in the clinic. While some are actively involved with the intervention, there are others who show interest but

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are not ready prepared to take the screening process on as a new ritual in the clinic. Another example I give you is from an earlier time during the intervention:

Today there were 3 eligible women for the trial but only one was screened because 2 said that they were having a CS no matter what. It is consistently reoccurring in the clinic and the midwives are placid enough when a woman comes in and says that she is having a CS and there is no other way to birth. I must keep an eye on this and see what is happening in these interactions, from both the midwife and the woman perspective. At least the women that are being screened are positive about what the trial aims to achieve and that the midwives perceive it in such a way that they feel good about the trial. But this is only with the 2 midwives that are constantly screening the women. I have yet to really see another midwife screen a woman for the trial. I can see that it is always the same midwives who are screening the women. They seem to be the older, more senior midwives in the clinic. This is interesting to note because it is becoming part of their routine to check for women but not the rest of the clinic staff. (Field-notes, April, 2014)

By June of 2014 the lack of recruitment of women to OptiBIRTH had reached a crisis point. The study was behind schedule and it became obvious that something was not working in the clinic, meaning that not all of the women who were eligible for the intervention, were being screened and recruited. This can be seen with the field-note below:

She asks with if I was the “one doing the VBAC study” and then begins to ask how it was going (rates of recruitment and interest from the women). This is a constant process that I go through with staff in the clinic. There is this interest that they have in seeing how the study is going and if recruitment for the intervention is going well but from what I can see this interest is not translating into action from some of the staff. I am not saying that this is the case for all staff but the ones that are screening are in the

minority. The midwives that ask me how the intervention is going are normally the ones that are not screening which is interesting to note.(Field-notes, June 2014)

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The liminal state of the rite of passage for the intervention in the antenatal clinic showed that with some members of staff, the recruiting and screening phase of the intervention was taken up in a positive way. However, these staff members were in the minority.

As I was waiting for more women to come in I checked the cabinet to see if any women were screened this week and 2 more women were screened since I was here last, by both a midwife and a registrar. In my opinion, these two members of staff are screening women because they believe in the ethos of the intervention and are motivated to check the charts and see if women are eligible. They are making this part of the intervention part of their clinic routine. They have successfully incorporated the checking of charts and screening of women into the rituals and routines that they apply in the clinical setting. It is also an interesting development to see that a registrar has become involved in the intervention process. Since I have been in the clinic I have found it difficult to access this side of the clinic and thought that they would not have any interest at all, instead leaving it for the midwives to do. But instead, this registrar is allowing the intervention to enter her routine in the clinic because she is motivated and really believes in VBAC.(Field-notes, June 2014)

It was a very frustrating and worrying time for the MOL and myself as I, thinking in a selfish way, was not getting any data that was relevant to this ethnography. Yet, on the other hand, the midwives and doctors were beginning to treat me not as a „stranger‟ or a person who was there „auditing‟ their practices, but rather they were beginning to welcome me more into the main clinic. I was also in a liminal phase at this point. In the clinic, I was being seen as „OptiBIRTH‟, but at the same time after being in the clinic full-time for six months (July 2014), I was beginning to transition away from

OptiBIRTH towards being seen in the clinic as someone who could help them and not judge their practice. An example of this is where I was invited to come up to the island when the clinic was not busy and chat to the midwives about the intervention or the clinic in general, and I was also allowed to gather charts from women bringing them

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from ultrasound to the clinic at the main entrance. It was at this point I believe that I was able to make myself useful to the midwives and this helped greatly when it came to observing in the clinic and in discussing with midwives their thoughts and perceptions of VBAC and how the subject is treated in the hospital. Yet, even though this added participation in the clinic was good for myself as an ethnographer, it was not good for OptiBIRTH‟s screening and information process in the clinic. It was only with the influence of the MOL coming down to the clinic most days after being informed by OptiBIRTH of the recruitment being behind schedule and doing the screening herself that the midwives began to take notice of the intervention. They began to realise that this is what they were supposed to be doing regarding the screening of women, and the intervention began to become entrenched in the clinic. However, this may have been due to the MOL taking over the role of the screening form and talking to the women in far greater detail than the midwives in the clinic.