Caught in a “Triple Bind”: How the physical body experiences paradox

Family interviews

Midwives and their family members were interviewed together, either in person (N = 20) or via Zoom (N = 27). In-person interviews took place in participants’ homes. Four interviews involved two family members alongside the midwife. Following a semi-structured guide, interviews lasted 93 minutes on average (range = 70 minutes – 2 hours, 40 minutes) and were digitally recorded. Interviews were transcribed by a professional service, and we sent transcripts to participants for accuracy and confidentiality checks before commencing analysis.

Observational notes

We made observational notes after interviews regarding our impressions of relational dynamics between midwives and their family members. We used these notes to enrich our reflexive understanding of how distinct family units experienced and responded to knotted tensions (see Findings).

Contractual documents

We gathered and read key contractual documents, such as the maternity services contract between LMC midwives and the NZ healthcare authorities (New Zealand Gazette, 2023). These documents supported our understanding of LMC midwives’ contractual obligations and payment terms and, by extension, how and why they experience business–care tensions (see Findings).

Descriptive coding

We began analysis by coding the entire dataset line-by-line to develop descriptive themes. The aim of descriptive coding was to understand participants’ experiences in their own words (Miles et al., 2014). We achieved this by developing a coding framework which we applied iteratively to subsets of data (King, 2012). First, all authors read a subset of transcripts and noted potential codes and themes. The first author then collated these notes to develop an initial coding template, which we uploaded to NVivo along with all interview transcripts. We coded five transcripts at a time, updating the coding framework after each subset by adding, removing, or collapsing codes and themes, until we had coded the entire dataset.

Pattern coding

We conducted pattern coding to surface themes with the potential to yield theoretical insights (Miles et al., 2014). During pattern coding—which took place over multiple rounds—we asked “questions” about the relationships between descriptive themes and codes, thus identifying theoretically interesting puzzles (Grodal et al., 2021). For example, having noticed overlaps between the themes gendered profession, motherhood, and gendered work–home tensions, we asked: How are midwives’ gendered identities as midwives and mothers/wives interconnected, and how do interdependencies between these identities generate tensions that midwives embody in their daily lives? We iteratively reconfigured our coding framework multiple times to interpret the data in line with such questions (Grodal et al., 2021). These reconfigurations involved developing new coding categories, merging others (Grodal et al., 2021), and incorporating concepts from related literature. During the final reconfiguration, and based on feedback from anonymous reviewers, we developed “embodiment of tensions” and “bodily impacts” as central themes. To deepen our understanding of these themes, we incorporated ideas from research on gender identity and power relations (e.g., Putnam & Ashcraft, 2017; Ravenswood & Harris, 2016) and paradox knotting (e.g., Sheep et al., 2017), thus developing coding categories such as “embodiment of gendered role tensions through presence–absence.”

Case summaries

We wrote detailed case summaries to gain a holistic understanding of how midwives experienced tensions within the context of each family unit. These summaries were written as narratives, drawing on observational notes and stories shared in interviews to detail how midwives and their family members experienced and responded to tensions over time and in response to changing interpersonal and structural power dynamics.

Theorization through visual depiction

We used visual depictions to theorize from themes in our data (Pradies et al., 2023). We developed visual depictions by iterating between case summaries, the themes surfaced through pattern coding, and the literature. Visual depictions were particularly appropriate for representing our findings because they enabled us to present themes as dynamic rather than static (Pradies et al., 2023).

Midwives’ physical embodiment of work–home care tensions

We found that midwives’ experiences of embodied paradox center around a persistent and interdependent tension in their work and home lives. Figure 1 illustrates this tension, showing that in both the work and home domains, midwives view themselves as carers who tend to put others first. At work, midwives put their clients first; at home, their family members. As one participant stated: “[C]learly, within me there’s a big caring part of my personality that, you know, I validate myself around caring for people” (Roxy, current LMC midwife (C-LMC)). This holistic self-concept as “selfless carers” is expressed in midwives’ interdependent gendered identities as both “good midwives” and “good mothers/wives.” Our participants often discussed how these identities were synergistic for them—implying interdependence—because the values of midwifery are closely aligned with those of motherhood:

[J]ust as midwifery changed my parenting, parenting changed my midwifery. I mean, philosophically, I think motherhood’s absolutely paramount to the [midwifery] community and all that, so not only is it important for me to honor these mamas [birthing women], but it’s also important for me to, when I was there, to honor myself as a mother. Anne, C-LMC

Consistent with this notion of dual role interdependence, our participants frequently stated that they chose to become LMC midwives after positive experiences during their own pregnancy and motherhood journeys:

I wanted to be an LMC since I had my daughter when I was 17. And I saw my midwife as someone that I respected and looked up to and I wanted to be like that. I wanted to be that person. And so I just found it really interesting, the whole pregnancy and birth and that relationship that LMCs have with women. So I only ever went into midwifery wanting to be an LMC, not working in a hospital or anything like that. Samantha, C-LMC

Echoing Samantha, other participants stated that their mission as LMC midwives was to empower women in their motherhood journeys: “Watching women become mums is why I do midwifery because it’s amazing. . . I very clearly believe that if there is a catalyst for change in a woman’s life, it’s being pregnant” (Beth, former LMC midwife (F-LMC)). Midwives’ family members—especially their daughters—supported this synergistic perspective of midwives’ work and home roles, discussing how their mothers’ midwifery practice had inspired and empowered them in their own lives and bodies:

I think I have learnt a lot on a personal level as a woman. Growing up with a midwife mum, I know a lot about my body, I know a lot about the system, and I feel very confident and comfortable with a lot of medical things that maybe some of my friends would have no idea about, but because of my mother, [I do]. Taylor, daughter of Swift, C-LMC

Collectively, these examples suggest that midwives’ work and home roles are inherently interconnected and synergistic. Who they are at work is inseparable from who they are at home. “Motherhood” is a central concept connecting these dual roles. Through their work, midwives empower birthing women to become mothers and, in doing so, they empower themselves as mothers who empower their own family members.

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Figure 1.

Midwives’ embodiment of work–home care tensions.

However, because of contemporary social organization, midwives often feel forced to treat their roles as separate and competing rather than connected and synergistic. More specifically, midwives’ gendered work and home roles are frequently pitted against each other in a zero-sum trade-off, where time and energy spent caring for clients is seen as detracting from family care responsibilities, and vice versa. In turn, this perceived either/or choice triggers tensions:

I feel like I’m letting everybody down. It’s so hard to do a good job and be a good mum, and I’ve not been a good mum because I’m tired; I’m never there for things. I’m not a good wife because poor John has to pick up the pieces so much, and that’s not fair and it’s not fair to make people feel like this. And we work our asses off to make sure that women get what they need, and nobody gives a toss about us; nobody cares about how hard it is for us, and all I ever wanted to do was be a midwife and I did it for love. . . and [now] I feel terrible that I’ve let the kids down so much. Jane, C-LMC

As this quote implies, midwives do not merely perceive work–home care tensions cognitively and emotionally; they experience them as physical states and sensations in their bodies. Our participants reported experiencing tensions as states including absence (“I’m never there for things”), fatigue (“I’m tired”), exhaustion (“I was so tired I couldn’t talk”; Joanne), and stress (“the stress I carry is enormous”; Olivia). They also experience them as quasi-physical sensations such as feeling “torn,” “overstretched,” or “spread too thin.” Moreover, midwives’ bodies are not just “sensors” that perceive paradoxical tensions, but sites in which the tensions are persistently enacted. As illustrated in Figure 1 and captured in the following quotes, this physical embodiment of tensions occurs because midwives’ conflicting yet interdependent care roles both require presence and energy—resources that are inherently limited by physiological and material realities:

You [midwife speaking to daughter in the interview] would be there with one of your brothers, and the place was in chaos, and I’d come home and I’d just go – “Don’t talk to me.” I’d shut myself in the lounge or something and I’d say – “I do not want noise, I do not want any. . .” I just needed to switch off from being needed. That’s a hard thing to do as a mother when you’re actually trying to teach and be a role model to women as to how to parent, and doing the exact opposite on the home front. Carrie, F-LMC

I’ve got a really vivid memory of the birth we were talking about where I had gone back and [my youngest son] was still needing to be [breast]fed, of sitting in the old theatre room bawling my eyes out, going – “I can’t give anyone what they need right now.” Yeah, it’s like – I can’t be a great midwife because I’ve got to be there for my kid, and I can’t be a good parent because I’ve got to be there for this woman, and just not feeling like I could do anything well. Debbie, F-LMC

Statements from midwives’ family members captured the same notion of work–home care tensions materializing in bodily limitations of presence and energy:

You know how all your studies say that LMC midwifery is really great for women because they have the one-on-one care? I mean, I can pretty easily explain to you why it’s so great. You’re going through this huge change in your life, and you have the opportunity to have someone right there, right by your side; not a parent but a parental role. They’re there to answer your questions. They’re there to support you emotionally, socially, talk you through it. And what happens there is that a [midwife] is able to provide that support for their client, but gaps start to appear, and they’re maybe not able to put all of that energy into their own children if it’s going into their clients. Margaux, daughter of Cate, F-LMC

Midwives also discussed how personal and family life make it difficult to consistently show up with the presence and energy to care for clients:

[After separating from my husband] I still needed to turn up to work and I still needed to turn up for those women, and I’d be sitting in the car and I’d be crying and then I’d have to wipe my eyes and put on my big girl knickers and go into a house and do a postnatal visit, or whatever. Cate, F-LMC

In sum, midwives embody a paradoxical tension between their conflicting yet interdependent work and home roles. The tension is enacted in bodily limitations of presence and energy, as recognized by both midwives and their family members. As we show next, these work–home care tensions become knotted with business–care tensions due to the structure and organization of LMC midwifery work, amplifying their embodied expression.

Knotting of embodied work–home care and business–care tensions

Under the LMC midwifery model, midwives must operate as small business owners: “We have to set up our own business. We’re our own administrators. We’ve got to sort out our own software, our own accounts, all that sort of thing” (Linda, C-LMC). At the same time, midwives have a duty of care toward their clients, which they typically internalize to the point that it constitutes an integral part of their identities: “[I]t’s about that journey with women and it just, you know, I think really it has to be in your heart and soul” (Linda). These elements of LMC midwifery create a persistent and interdependent tension between business and care imperatives, which is amplified by the funding structure of LMC midwifery. Dedicating high amounts of time and energy to client care is often at odds with the financial viability of midwives’ business operations because it detracts from their ability to earn additional income by caring for other clients. Yet, providing high-quality client care is essential to the viability of midwives’ business operations given that (a) midwives must attract their own clients and (b) clients “rate” the quality of care provided by specific midwives, which informs other prospective clients’ midwife selection decisions. One midwife captured how this interdependent business–care tension manifests in midwife–client relationships when she stated: “[Y]ou’re trying to balance trust and connection with efficiency and boundaries and getting the job done” (Cate, F-LMC).

We found that midwives’ experiences of business–care tensions become knotted with work–home care tensions in a “tripolar” paradox. Figure 2 illustrates this paradox, showing how work–home and business–care tensions are connected by their shared “client care” pole. An unwavering commitment to client care is deeply embedded in the professional values of midwifery; midwives internalize and embody this commitment to the point that it often shapes their entire self-concept: “I couldn’t imagine me not being a midwife. Like, it’s part of who I am” (Gael, C-LMC). With client care so central to midwives’ identities, it is easy for work obligations to become part of their personal lives. The structure of LMC midwifery encourages this tendency by eroding work–home boundaries. For instance, due to midwives’ on-call obligations to clients (which they must honor to get paid), midwives frequently receive and respond to calls and messages from clients while at home: “[We]’d be sitting at the dinner table and she’d take a phone call at the dinner table and continue to talk through whatever was going on in the pre-birthing process as this person’s going into labor while we’re trying to eat dinner” (Lilly, daughter of Carrie, F-LMC). In turn, “client care” connects work–home and business–care tensions in a configuration that creates an additional tension between midwives’ family care responsibilities and business imperatives (“family care–business tensions”; see Figure 2). For example, the workload of client care that midwives assume to remain financially viable detracts from the time and energy they have for their families, as do business-related tasks such as billing, documentation, and addressing client queries. At the same time, the financial returns of midwives’ business operations enable them to support their families financially, implying interdependence between family care and business imperatives.

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Figure 2.

Tensional knotting produces tripolar paradox.

The configuration of paradox poles represented in Figure 2 means that midwives must attend to three sets of interconnected tensions concurrently. Our data suggest that these tensions are often mutually amplifying. For example, the following quote illustrates how family care–business tensions amplify business–care tensions:

When we’re trying to earn a living and support a family, you can’t be doing all of the [care-related] things because how much we get paid is per woman; the more women you take, the more you get paid. But if we’re doing every little piece of their care, it makes it really difficult. Sarah, C-LMC

The data also show how midwives simultaneously experience and enact all three knotted tensions with their bodies, creating an immense physical burden. For instance, a former LMC midwife described a typical scenario (for her) in which her body was stretched between client care obligations, family care obligations, and business imperatives:

Examples are, you come back after 28 hours up at the hospital, really hard birth, you’ve had no sleep for days, and I used to be fully pregnant at that stage as well. I’d come home and then it would be like – “What’s for dinner?” And all the kids would be there. While the kids are being looked after by my partner, and I owned the house, I paid all the bills, I owned all the vehicles as well, so it was difficult because then I was like – There’s no washing being done and no groceries being bought; no meals had been planned, the kids have had toast or whatever every day. Sometimes if they were little, they might be a bit constipated. . . So, I might come home after that 28 hours, fully pregnant, but I still had to breastfeed my other baby and be up every three hours at night, and waiting on another birth. My partners haven’t been that understanding of that, and they still want their needs met, so they still want sex, or – “You don’t seem to have as much energy,” or, “Why do you have to do that paperwork now, can’t you leave it?” It’s like – “I can’t leave it.” Or – “Do you have to work today?” It’s like – “Well, that baby that I delivered the other night is now due a blood test, so I have to go.” Bella, F-LMC

This quote hints at another important role of “the body” in midwives’ experiences of knotted tensions. Midwives not only feel paradoxical tensions as embodied states and enact them with their bodies; they also experience the tensions as being shaped by the pull of other physical bodies. For example, as implied in Bella’s quote, the timing, duration, and intensity of LMC midwives’ client care responsibilities are influenced by the physiological realities of pregnancy and birth; midwives typically have no control over when clients go into labor, and they have little control over how long births last. Likewise, family care responsibilities are influenced by bodily processes and drives (e.g., constipation, breastfeeding, libido). The two “care” poles in the paradox knot thus exert a “bodily pull” on midwives that business imperatives do not.

Often, LMC midwives accept the tensions arising from the material constraints of bodies because they view them as inevitable outcomes of physiological processes:

From what I saw, Mum would come home after a birth and she’d be like – “You should have seen. . . blah blah blah blah blah; this happened and this happened.” So she’d tell me all about the birth and how much she loved it. She would never come home and be like – “That was so long.” It was always like – “Oh!” Chelsea, daughter of Debbie, F-LMC

Honoring such processes aligns with midwives’ self-concepts as experts in—and advocates for—normal, physiological approaches to pregnancy and birth:

We’re experts in straightforward, normal pregnancies and maintaining that, and then experts at, I suppose, diagnosing deviations from normal or when complexity arises. . . For me, what I enjoy about [the LMC model] it is that if a woman really wants to be supported in her pregnancy, I can choose to do that with all of the clinical details of that being known to me. For example, if somebody said – “It’s my first baby, the baby’s breach, I want to have the baby at home” – I can do that for her. If I was an employed midwife in [a hospital] – “No, we don’t support home births in our region” – that woman’s then left without an option, and that sovereignty to choose her care is really important, and being able to support her to do it. Lynn, C-LMC

However, because of paradox knotting, midwives’ attempts to navigate embodied tensions are influenced not only by material constraints of others’ bodies but by the social organization of midwives’ work and home roles. As we show next, this social organization involves a complex configuration of interpersonal and structural power relationships.

Living and working within the constraints of the triple bind

A triple bind suggests a practically inescapable situation, even more difficult to navigate than a double bind. Yet, many of the midwives in our study had long careers as LMCs and also raised families. How did they manage this feat and what were the consequences?

Our data suggest that because midwives experience their triple bind through bodily limitations of presence and energy, they depend primarily on interpersonal support to navigate its constraints. Such support comes from three main sources—midwives’ families, coworkers, and clients—and takes three predominant forms: embodied support, body substitutions, and body free passes. Embodied support is material assistance that helps midwives cope with the conflicting demands of their work and home roles. Family members are typically the ones providing this support to midwives, enabling them to temporarily ignore one paradox pole (e.g., family care responsibilities) to focus on the others: “I will walk out the door and go – ‘Tea [dinner] is nearly ready, you just need to do this, this and this’. . . and he [my husband] just picks up where I leave off” (Maree, C-LMC). In situations where midwives’ bodies are stretched between care and business imperatives, family members may provide embodied support by not only caring for themselves (alleviating work–home care tensions) but by actively assisting midwives to meet both client care and business obligations (such as attending back-to-back births to get paid for client care modules). For example: “Mum would have two back-to-back births, and even when I was still at home we used to drive out to [small town] to drop off food and to make sure she was ok, and bring her blankets or clothes if it was cold” (Poppy, daughter of Lucille, C-LMC).

Body substitutions occur when midwives have somebody “stand in” for them in one of their conflicting roles. LMC midwives often work within self-organized practice groups with a dedicated “backup.” Backups cover periods of short-term leave reciprocally, enabling the other midwife to, for example, attend family occasions without shirking client care obligations. However, because the arrangement is reciprocal, midwives are responsible for their backup’s full caseload of clients when it is their turn to cover. Consequently, short-term alleviation of work–home care tensions is often followed by an amplification of tensions due to workload pressures. Business imperatives ensure that midwives cannot use body substitutions excessively without negative financial repercussions (because they will lose care module fees), emphasizing the tripolar constraints of the paradox knot. Midwives’ family members—especially partners—may also act as body substitutes: “If Lagatha gets called to a birth and the kids are on their own, then I’ve got to drop my arrangement. . . and come home and look after the kids” (Graham, husband of Lagatha, C-LMC). However, without an enduring gender role switch (see Response Pattern 3), this sort of body substitution provides only temporary relief from work–home care tensions. Moreover, we found that the “tone” of body substitutions influences the experiences of associated tensions; if partners are resentful about “standing in” for midwives, their “support” may actually heighten midwives’ feelings of tensions.

Body free passes are permissions granted to midwives by family members or clients, enabling midwives to (temporarily) neglect one of the three paradox poles without it amplifying their feelings of tensions. We found that when body free passes are combined with embodied support and/or body substitutions, they are highly effective at alleviating work–home care tensions in the short term. For example, clients can be understanding that because a midwife has her own family obligations, she will get her backup to attend their birth. Similarly, family members can forgive midwives for neglecting home-domain responsibilities and missing family occasions due to work commitments; or for having no energy and needing to sleep when they get home from work; or for having to spend their evenings on business-related paperwork. One husband captured this kind of forgiveness when he said:

I totally respect what she’s doing, and I think all of us are really in the position to do everything we can to support her to do that. Sometimes the house might be messier than any of us can handle but it’s all right, that’s life, we’re not going to die. As far as I know we’ve never left the kids at school and no one’s gone to pick them up, they’re still here so that’s all good. There’s no question there’s been some challenges but you’ve just got to get over it and deal with it. Bob, husband of Sarafina, C-LMC

As this quote suggests, family members are more likely to grant body free passes when they recognize and respect the value of LMC midwifery work. Conversely, they are less likely to grant such passes when they feel midwives are overworked and undervalued as part of an exploitative relationship with the government (see Response Pattern 3). This is especially true when midwives require free body passes regularly and over long periods.

The three forms of interpersonal support just described illustrate the dynamic fluidity of interpersonal power relations and how they influence midwives’ experiences of embodied tensions in short-term cycles. For example, family members and clients might temporarily relinquish their perceived power over midwives by forgiving midwives’ absences or tiredness through body free passes. However, such interpersonal support provides only temporary relief from tensions because it does not reconfigure the underlying power relationships that perpetuate tensions over time. To illustrate, a husband can look after children when a midwife gets called to a birth, and children can forgive her for missing important occasions, yet the midwife still feels guilty because she continues to embody the gendered role of primary caregiver.

Accordingly, we found that while midwives can survive the triple bind with adequate interpersonal support, they rarely thrive within its constraints. For instance, no midwives in our study described feeling “energized” by navigating family care, client care, and business imperatives simultaneously. To the contrary, most felt worn down by the cumulative fatigue and stress of trying to “be everything to everyone” (Samantha, C-LMC). A former LMC midwife captured this notion as follows:

I think it was always just trying to juggle; it was always trying to not let anybody down and do the best job I could, and I guess it’s like that analogy of holding a glass of water; you can hold a glass of water out for a period of time without any problem, but the stress of trying to make sure everyone was happy and everyone was covered and catered for, and I didn’t make a mistake at work, I didn’t let anyone down, I always turned up when somebody called – the stress of that was taxing over a period of time. Joanne.

Our data suggest that cumulative fatigue and stress have enduring impacts on midwives. For example, one midwife participant had recently retired from a long career as an LMC midwife (25+ years in LMC) during which she and her husband raised two children. When asked how she balanced the responsibilities of being a mother, a midwife, and a small business operator for so long, she signaled the importance of support from her husband (embodied support, body substitutions) and understanding from her children (body free passes). But she also said: “[It] became an issue that you were exhausting yourself because you were trying to be in three places at once.” When asked how such efforts impacted her personally, she said, “I got older quicker. I got more wrinkles earlier. And yes, there is a lot of guilt.” Other participants described not only physical and emotional impacts similar to these, but a relational toll associated with relying too frequently on support from family members (especially body substitutions and body free passes). Some had broken marriages or grown children who no longer talked to them.

Notably, a shift in the “balance” among paradoxical demands occurs over time for LMC midwives. When children are younger, they require more direct energy from midwives’ bodies, amplifying tensions between family care and client care. As children grow up, they demand more financial support, amplifying family care–business tensions (and, by extension, business–care tensions). Our data suggest LMC midwives are more likely to navigate this dynamic balance “successfully” if they have adequate interpersonal support to survive periods when demands on their bodies are most intense. However, such short-term support does not always protect midwives from long-term physical, emotional, and relational impacts.

Work-domain role shift

We found that midwives who lack the interpersonal support to navigate the demands of their triple bind typically escape its confines through a work-domain role shift. Most commonly, LMC midwives move to hospital-based “Core” roles (see Research Context). This shift reconfigures the underlying paradox knot by removing the “business imperatives” pole, as shown in Figure 4. As employees in hospitals or clinics, midwives are not required to attract their own clients or manage their own finances. Instead, they enjoy a stable (though not necessarily higher) income and benefits including sick pay, annual leave, and retirement fund contributions. However, as explained later, this work role shift typically entails an “integrity sacrifice” because it reintroduces another set of restrictive power relations.

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Figure 4.

Visual depiction of Response Pattern 2: Work-domain role shift.

In our study, midwives who had shifted into Core roles frequently did so after realizing they could not navigate—or tolerate—the embodied demands of the triple bind. For example, Cate struggled to balance client care against family care and business imperatives. The ensuing tensions were amplified when she separated from her husband, leading to a body breakdown and an eventual exit from the LMC role:

I remember one time I was coming out of a virus and then I got food poisoning and it was just awful, and I just knew I wasn’t coping; I knew my body wasn’t coping, I just knew that my body was just going – You can’t do this, this is too hard, this is too much, just the weight of everything, yeah. I actually went to a counsellor to try and work out how I could do my life in a way that was manageable because I loved being an LMC; I adored working with the women, I love the continuity, I love birth. . . . I love it so much and I went to see a therapist because I couldn’t understand how I could manage my life, and it was she who helped me understand I had to leave LMC midwifery. Cate, F-LMC

As illustrated by Cate’s story, midwives who left LMC work for Core roles often did so with a sense of regret. Regrets most often stemmed from losing one-on-one connections with women and the autonomy to honor women’s bodies and choices: “If you become a hospital-based midwife there’s definitely a degree of subordination that happens, that suddenly the midwifery team default to the obstetric opinion” (Lynn, C-LMC).

Our analysis suggests the regrets associated with a work-role shift are due to the loss of potential synergies between two paradox poles—client care and family care—that occurs with the unravelling of the paradox knot. As depicted in Figure 4, shifting into a Core midwifery role removes the “business imperatives” pole, obviating the need for midwives to navigate business–care and family care–business tensions. To an extent, this is beneficial as midwives must no longer contend with the patriarchal-capitalist power structures that can transform these tensions into debilitating either/or choices. However, when they move into the Core system, midwives face hierarchical organizational structures that prevent them from advocating for women’s control over their bodies. Thus, the potential for synergies between family care and client care—such as self- and family empowerment through the empowerment of birthing women—are lost. In turn, work–home care tensions become disconnected, and midwives experience an “integrity sacrifice,” feeling like they’ve lost an integral part of who they are:

I’m not fulfilled in a Core role; I don’t even feel like it’s midwifery and it’s splitting off into complex care nursing but there’s no autonomy; it’s very different. I used to get so much internal reward out of the relationships I had with ladies. Bella, F-LMC

Home-domain role reversal

The final response pattern we identified is a home-domain role reversal that midwives negotiate with their partners. In this pattern, partners do not just act as temporary body substitutes but perform longer-term role reversals. As illustrated in Figure 5, such reversals relieve midwives of tensions associated with their gendered body roles as primary caregivers and homemakers. One midwife captured the essence of this approach when she stated: “I would say a midwife needs a wife, and Johan [the midwife’s husband] has been a wife” (Roxy, C-LMC). The husband of a former LMC midwife also described how they enacted a gender role reversal in their household, enabling the midwife to provide for the family as the main breadwinner:

Serena was the main income. . . she definitely earned more than me. . . It’s a reverse, I suppose, of a paternalistic arrangement where it’s always the woman’s at home and the man just wanders off and does what he wants and comes back when he’s had enough. This was just the flip of that. So, it’s no different to any other family, it’s just the roles were reversed in this case. Richard, husband of Serena, F-LMC

A home-domain role reversal reconfigures the paradox knot underlying midwives’ triple bind, as shown in Figure 5. Specifically, it removes family care responsibilities requiring bodily presence and energy. Yet, the reversal simultaneously increases financial responsibilities associated with family care. Accordingly, as breadwinners, midwives experience heightened family care–business tensions and, due to paradox knotting, amplified business–care tensions. The crux is that gender role reversals are contingent on midwives earning enough to provide for their family. However, due to the LMC funding structure, LMC midwives can only increase their income by taking on more clients: “My caseload was probably about 100 a year. . . [M]y husband didn’t earn a living, so it meant I was the primary earner, and had a mortgage to pay and all the rest of it” (Olivia, C-LMC). Since increasing one’s caseload typically reduces quality of care, becoming a breadwinner amplifies business–care tensions.

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Figure 5.

Visual depiction of Response Pattern 3: Home-domain role reversal.

We found that couples who had successfully undertaken a home-domain role reversal generally did so 20+ years ago. Since then, societal changes brought about by neoliberal capitalism have made it increasingly difficult to balance business–care tensions in a way that makes the breadwinner role sustainable for LMC midwives (unless their children are grown up and fully independent). For instance, neoliberal economic policies have increased inequality in NZ, raising the prevalence of mental and physical health issues among clients, and reduced government funding for the healthcare system. In combination, such factors have increased the workload of LMC midwifery while reducing inflation-adjusted financial returns.

In the current environment, midwives trying to navigate their triple bind with a home-domain role reversal end up in a secondary bind that reinforces prevailing patriarchal-capitalist power structures. Negotiating a home-domain role reversal requires that midwives effectively balance business–care tensions. But due to the LMC funding structure, midwives experience this paradoxical tension as an either/or choice. Either they can: (1) take a business-oriented approach toward client care and, in doing so, sacrifice their integrity by tacitly submitting to patriarchal-capitalist power structures that treat care as a lowly valued commodity (an approach that may also have negative business repercussions due to clients’ “ratings” of midwives); or (2) they can sacrifice their bodies by trying to provide both quantity and quality of care: “[You] work 36 hours on the trot without [a break] ‘cause you’re so desperate to make sure that women get the care they need and deserve” (Olivia, C-LMC).

Most midwives in our study were unwilling to treat care as a commodity and instead prioritized their clients’ welfare as a means of resisting capitalist economic logic. Our participants often implied that this resistance was driven by a feminist political agenda:

Because it’s women giving birth. We’re 99.9% a female workforce, so we are expected to – Oh well, just have your child, or you’ve got your period that day and you might feel tired. Well, you’re expected to go out and do that and you’re not getting any time off, and we don’t get sick days. So you carry on in your stoic bag because you’re a woman helping another woman, so it makes you even more determined to get through and advocate for them. Lucile, C-LMC

However, our analysis suggests that midwives’ resistance has the paradoxical effect of reinforcing their relative powerlessness in the healthcare system. Midwives recognized how their prioritization of care enables the healthcare authorities to take advantage of them:

I think LMC midwifery possibly would’ve collapsed if it was a different type of person or men to be general, you know. No one else would put up with the conditions and the pay and the, yeah, the shit that we put up with if we weren’t nice people and everyone’s worried about their women. Amy, C-LMC

Spouses and partners concurred with these sentiments:

As long as you keep enabling the system to take advantage of you [speaking to wife during interview], then in some way you’re actually part of the problem, because you’re enabling the system to take advantage of you, basically. . . I don’t think there’s a silver bullet, but I certainly think there’s a lot of things that happen simply because most of your colleagues and you just want to do right by your [clients]. Dave, husband of Kate, C-LMC

Accordingly, Response Pattern 3 shows how patriarchal-capitalist power structures that influence midwives in the work domain (by simultaneously commodifying and devaluing maternity care) prevent them from challenging patriarchal gender norms at home. Midwives struggle to negotiate gender role reversals with their spouses and partners because, ironically, the latter view LMC midwifery as an undervalued and exploitative work model. In turn, these failed negotiations reproduce the interpersonal power relations midwives were trying to renegotiate, and the triple bind “reknots” around them (see bottom left corner of Figure 5).

Non-cognitive dimensions of paradox

Our concept of the triple bind advances understanding of the non-cognitive dimensions of paradox navigation. Traditionally, paradox research has emphasized the importance of cognitive approaches such as both/and thinking (Smith & Lewis, 2022), paradoxical frames (Keller et al., 2017), and paradox mindset (Miron-Spektor et al., 2018). Recent research highlights that paradox navigation also entails emotional and relational elements (Pamphile, 2022; Pradies, 2023). Our research takes this non-cognitive perspective a step further by empirically examining the role of the physical body in experiencing, enacting, and responding to paradox. In our study, embodying paradox refers not only to when somebody represents contradictory yet interdependent poles (Bednarek et al., 2017), but to when physical bodies feel and enact paradox through materially constrained polarities such as presence–absence and energy–fatigue. Our empirical exploration of this phenomenon builds on Fairhurst and Putnam’s (2023) conceptual work, elaborating their contention that bodily reactions reflect the power conditions under which paradoxes are experienced.

Our embodied perspective supports the problematization of widespread assumptions regarding the primacy of cognitive approaches in paradox research (Berti & Simpson, 2021a; Seidemann, 2024). Our findings imply that, as delicately balanced physiological systems, bodies face material constraints in ways that cognitive systems do not. In persistently enacting complex, demanding tensions, bodies are subject to enduring physical impacts regardless of how individuals mentally conceive of the relationships among paradox poles. Indeed, the midwives we interviewed often thought of their dual identities (as “mothers/wives” and “midwives”) as interdependent and synergistic. What prevented them from leveraging these synergies were interpersonal, structural, and material constraints embedded in imbalanced power relationships. Consequently, our paper emphasizes that bodies cannot navigate power-constrained paradoxes without material and interpersonal support (Pamphile, 2022), and we illustrate how embodied support, body substitutions, and body free passes help loosen the constraints of the triple bind in short-term cycles. At the same time, our findings highlight the limits of such support to protect against long-term impacts when structural power relations constrain available responses to underlying paradoxes (see Response Patterns 1 and 3).

Our work suggests several directions for further research on the body’s role in paradox. To start, it encourages practice-based scholars to examine how physical bodies construct and enact paradox through everyday actions (Jarzabkowski et al., 2017; Lê & Bednarek, 2017). In our care-focused context, paradoxes were physically enacted in polarities of presence–absence and energy–fatigue. But what polarities are involved in the physical experience of other paradoxes? Our research also suggests that bodies not only enact paradoxical demands but give rise to such demands. We showed how “the pull of other physical bodies” influenced midwives’ experiences of embodied tensions, and how paradox poles materializing in this pull (e.g., family care, client care) were internally more compelling than “disembodied” poles (e.g., business imperatives). This finding resonates with Pradies’ (2023) work showing how veterinarians have stronger emotional identification with care imperatives than business ones. Future research could more explicitly and comprehensively examine how bodies and emotions “work together” in paradox navigation. One might assume that bodies and emotions are close collaborators—but does this assumption hold true? For example, can emotional connections encourage bodies to navigate paradoxes in ways that undermine bodily health? And can the material constraints of other bodies encourage individuals to disconnect emotionally from those bodies? Lastly, although we focused on what Berti and Pina e Cunha (2023) would call a “pathological” paradox—governed by asymmetrical power relations—our work invites scholars to examine how bodies experience more generative paradoxes. For example, when leaders adopt a both/and strategy to engage paradox, how do the physical actions of implementing that strategy impact the bodies of organizational members? Both/and approaches to paradox are seen as a source of creative energy (Miron-Spektor et al., 2018)—but do bodily limitations affect individuals’ ability to remain energized by paradox over time?

Interconnections between power and paradox knotting

Our second area of contribution is to research on the interconnections between power and paradox knotting. Prior research shows that power relations can shape individuals’ interpretations of the interplay among multiple sets of tensions (Greenslade-Yeats et al., 2026) and that power structures can spawn new sets of tensions by blocking attempts to navigate underlying paradoxes (Amaral et al., 2025). Our study builds on this work by highlighting the physical body as a site in which both power relations and knotted paradoxes are enacted. Specifically, we introduce the concept of the triple bind, where paradox knots intersect with power asymmetries and physically demanding paradoxes. Under the triple bind, physical depletion acts as a “third dimension” of (material) constraint, compounding the interpersonal and structural constraints characteristic of traditional double binds (Putnam & Ashcraft, 2017). Future research could further examine the notion of physical depletion as a third dimension of constraint and, in particular, how it influences the experience of pathological and pragmatic paradoxes. For example, pragmatic paradoxes are typically described as “paralyzing” situations (Berti & Simpson, 2021a). Yet, literally speaking, subordinates receiving unrefusable and contradictory orders are unlikely to have the luxury of responding by not moving. Therefore, how do subordinates’ bodies experience the metaphorical state of “paralysis” associated with pragmatic paradoxes? Could some pragmatic paradoxes actually be associated with physically depleting hyperactivity?

In addition to revealing the material constraints of triple binds, our work advances understanding of how power and knotting jointly shape social orders. Aligning with a processual view of paradox in which “the micro constructs the macro” (Bednarek & Smith, 2024, p. 587; Jarzabkowski et al., 2017), we found that knotted paradoxes were embodied and enacted in practices that could simultaneously express, reconfigure, and/or reinforce prevailing power structures and relationships. More specifically, our theorization illustrates the self-reinforcing ways in which gendered power relations play out in paradox knotting (Putnam & Ashcraft, 2017). Building on prior research, our findings suggest that due to the devaluation of care work in patriarchal-capitalist societies (Tronto, 2013) and enduring narratives about gendered home-domain roles (Padavic et al., 2020), women may be susceptible to restrictive forms of paradox knotting that do not affect men. In turn, we demonstrate how paradox knotting can promote and maintain undesirable forms of social order (Acker, 2006) in addition to the desirable forms of order studied by other scholars (Jarzabkowski et al., 2022). Future research could examine the converse of our findings—namely, how knotting acts as a disordering mechanism (Jarzabkowski et al., 2022; Sheep et al., 2017) that reconfigures or overturns oppressive social orders.

Responsibility for navigating paradox

Our exploration of the links among bodies, paradox knotting, and power has implications for the question of who is responsible for navigating paradoxes. The dominant view, encapsulated in what Seidemann (2024, p. 11) calls the “hegemony of both/and,” is that focal actors who experience paradoxes are responsible for navigating them (Li, 2021; Smith & Lewis, 2022). Our work not only highlights the limits of this “individual responsibility” perspective but also offers ideas for alternative ways of addressing paradoxes through policy initiatives targeting systemic change. Starting with the limits of individual responsibility, our findings illustrate how the structure of the maternity care system forces midwives to choose between sacrificing their bodies and their integrity. The system forces midwives to sacrifice their bodies by putting them in a triple bind, where physical depletion compounds interpersonal and structural constraints. As documented earlier, this bind has serious ramifications for midwives’ health, which manifest either acutely or over the long term. However, midwives often choose to live within the constraints of the triple bind because the self-employed business model underpinning it also affords them the autonomy to provide women-centered care. Providing such care is integral to midwives’ integrity. Therefore, if midwives choose to leave the bind, they may save their bodies from the bind’s long-term health consequences, but they typically sacrifice their integrity by subordinating themselves to medical hierarchies in hospitals.

Who, then, “should” be responsible for navigating the paradoxes underlying midwives’ triple bind? One perspective suggests that midwives should cope individually by “reducing [their] expectations” (Li, 2021, p. 407). For example, midwives could concede that they can either have health (but lose integrity) or have integrity (but lose health). However, this individual responsibility perspective contradicts a core normative message of paradox theory—namely, that actors should not have to choose between interdependent options (Lewis & Smith, 2022). Therefore, enabling a both/and approach for midwives requires systemic change (Amaral et al., 2025; Berti & Simpson, 2021b), implemented at the policy level. Drawing on Mary Follett as inspiration, Bednarek and Smith (2024) suggest that individuals (such as midwives) could be integrated as active participants in designing and implementing such change, enabling the oppressive power-over dynamics of the current system to shift toward generative power-with dynamics (Schrage et al., 2025). For example, midwives could work with policymakers to cocreate a system where midwifery care is treated neither as a lowly-valued commodity in a fixed price market, nor as a subordinate type of care to obstetric approaches. Such a system would undoubtedly be far from perfect—it would almost certainly still challenge midwives’ health and integrity. Yet, the power-with dynamics underpinning the system would at least alleviate most midwives of the “your-body-or-your-integrity” choice they currently perceive. While this example is specific to NZ’s maternity care system, the broader message of how to facilitate constructive paradox navigation through systemic change is likely transferable to a range of other contexts where pathological manifestations of paradox are rooted in asymmetrical power structures.