An Illicit Way to Elicit Public Health Responses to Obstetric Violence: Poetic Inquiry of Open-Ended Survey Data

Poetic Inquiry

Owton (2017) describes poetic Inquiry as a ‘revitalizing and galvanizing mode of thought for humanistic study and teaching, making available means of engaging with and producing texts that are both very fresh and steeped in poetic tradition’. Poetry provides a template of representation for qualitative data that is a very particular form for understanding embodied experiences (Leavy, 2020). Poetic Inquiry involves a deep listening of the participant’s narratives and turning the narratives into poetry using ‘poetic devices’ (Chadwick, 2017). It enables the readers and listeners to receive the data and the narrative in a different light from a unique perspective. Owton (2020) proposes that poetry allows a reader to ‘step into another person’s experience’ and fully immerse themselves in it by using their senses of touch, smell, taste, hearing, and sight.

There are many forms of poetry based on the paradigm and data, but the most common forms are 1) researcher-voiced, 2) participant-voiced and, 3) literature-voiced (Leavy, 2020). Authors highlight the therapeutic nature of poetry (Etherington, 2004), and discuss that it should not be put on a pedestal but rather that it should be a method accessible to all. Poetic inquiry, unlike the other forms of traditional and quantitative methods of inquiry, pays attention to the nuances of experiences. It is a simple and yet powerful way of connecting and bridging the participants, researcher, listeners and readers (Rapport & Sparkes, 2009).

Voice Centered Relational Method

VCRM is used when creating participant-voiced poetry which represents about a third of poetic inquiry. VCRM is a feminist, relational and narrative method characterized by a series of guided listenings to center the voice of the participant, which recognizes their relation to others and the social structures, while being cognizant of the researcher’s voice and story in relation to the narrative (Gilligan et al., 2003; Hutton & Lystor, 2021; Ross, 2003).

The VCRM is both a method and methodology that originated in the field of psychology and has seen cross-disciplinary iteration and application (Gilligan et al., 2003; Hutton & Lystor, 2021). It attunes researchers to listen to both for the voice of the first person speaker, as well as the contrasting or “contrapuntal” voices. This methodology requires creation of different kinds of poems using direct quotes from qualitative data. One form is the Ipoem, which is constructed by selecting quotes that include the first person perspective or “voice” (Gilligan et al., 2003). The Ipoems are created to convey participant narratives that are representative of the recurring themes found within previously coded text. The purpose is to capture and elevate participants’ voices in a way that evokes readers’ emotions and move them into action. Ipoems are created from sentences starting with ‘I’; they elicit human emotions and experiences that reflect larger societal and relational dynamics and discourses.

VCRM allows the researcher and audience to step into the participant’s world which helps the researcher to empathize when in the process of meaning making (Hogue, 2006). Both VCRM and arts-based depictions of the themes are particularly impactful as the varying details presented through these poems, and related illustrations, allow readers to use the senses of sight, touch, hear and be moved by the power of these narratives (Hogue, 2006; Poindexter, 2002).

VCRM has traditionally been used to analyze in-depth interview transcripts involving a relatively small number of participants (Mayra et al., 2021). However, thematic and content analysis, which are usually applied to larger qualitative datasets of thin data, may not adequately center marginalized voices; recognize the researcher roles, experiences and vulnerabilities, or evoke responses to the subject to the same extent that VCRM has the potential to, through poetic inquiry (Leavy, 2020). Germane to the subject of this current research, VCRM was chosen in this study for its transformative intent-listening and potential to elevate marginalized and silenced voices of women, trans, and gender nonconforming people.

In this paper, we detail how VCRM was adapted for use with a large volume of thin data from a pan-Canadian community-based participatory study, representing a range of marginalized voices in a high income country. Highlighting both strengths and limitations to our approach, we describe how the application of VCRM and poetic inquiry to the analysis of responses to open-ended survey data on obstetric violence can (a) center and elevate participant voices, (b) situate the researcher positionality and reduce researcher vulnerability when engaging with a difficult subject, and (c) galvanize audiences into action, in distinct and novel ways. By doing so, we highlight how VCRM is particularly well positioned to study sensitive, difficult and potentially traumatic subjects by recognizing sensitivities surrounding the participant, the researcher, and the audience.

Obstetric Violence: A Case Study

Obstetric violence is a feminist concept that encompasses volitional and unintentional behaviors and procedures carried out during obstetric care that cause physical, emotional, or psychological harm to the people who give birth (Freedman et al., 2014; Sadler, 2016; Sen et al., 2018). Equally, it draws attention to systemic problems in the provision of obstetric care that represent violations when viewed at a population level, such as excessive rates of episiotomies and cesarean sections (Diniz et al., 2018; Sadler, 2016). With the examination of power central to how it is operationalized, obstetric violence as an analytic lens, sits at the intersection of structural, institutional, and gender-based violence (Freedman et al., 2014; Jewkes & Penn-Kekana, 2015; Mayra et al., 2022; Oliveira et al., 2002; Sadler 2016; Van der Waal et al., 2023; Šimonović, 2019). Researching obstetric violence is therefore complicated by the sensitive and often stigmatizing nature of the conversations related to reproductive health, as well as the patriarchal values and beliefs that historically have and continue to shape perinatal care and discourses around it, thereby rendering it an illicit topic to explore (Mayra et al., 2021; Pimienta et al., 2023). This is especially relevant in obstetrician-centered models of care, which are hierarchical and “mother blaming”, which can leave women and people who give birth voiceless, powerless and oppressed (Davis, 2008). For these reasons, exploration of obstetric violence is fitting for arts-based methods of inquiry, yet few examples exist in the literature.

A study used arts-based research methods to explore and understand the embodied experiences of obstetric violence in India (Mayra et al., 2022; Mayra, Matthews & Sandall, 2021). It analyzed in-depth narratives from eight participants using body mapping adapted as “birth mapping” (Mayra et al., 2022), as well as poetic inquiry to center women’s voices when reporting on experiences with obstetric violence and decision-making during perinatal care (Mayra et al., 2021). While pregnancy and birth experiences have been well researched through narrative methods, the above study by Mayra et al. (2021) sets precedence for using the VCRM, also known as ‘The Listening Guide’ to study the topic. Together with Chadwick (2017) who studied obstetric violence and birth trauma, and McKenzie (2021) who examined the phenomena of ‘free birthing’, these studies represent an important if not overdue departure from conventional research approaches to examine birth experiences, trauma and injustice through creative, arts-based methods.

Epistemology

Our study is embedded in critical feminist theory, which enables the interrogation of gender and power, that is central to the understanding of obstetric violence (Jewkes & Penn-Kekana, 2015; Mayra et al., 2022; Schaff et al., 2023; Sen et al., 2018). Critical feminist theory examines and challenges the ways in which systemic power relations, gender inequality, and intersecting forms of oppression are embedded within social, political, economic, and cultural systems. It emphasizes the transformation of unjust structures by critically analyzing how power operates across different contexts and deconstructing these systems of power, while centering the lived experiences and voices of marginalized groups (Crenshaw, 1989; Hooks, 1984; Hartsock, 1983). Critical feminist theory is not reductionist, but rather understands gender through social relations and how together they are produced, reproduced, transformed through living experiences while aiming for liberation, emancipation and empowerment of the oppressed (Katsiampoura, 2024). Many researchers have grounded their research related to women, women’s bodies and obstetric violence on critical feminist theory with this understanding (Chadwick, 2021; Keedle, 2019; Niles et al., 2021; Shabot, 2020).

Our inquiry was also operationalized by tenets of feminist standpoint theory and intersectional theory. Intersectional theory argues that traditional systems of power, such as racism, sexism, and classism, are interconnected and cannot be separated when analyzing inequality. Intersectionality highlights how individuals or groups situated at the intersections of multiple marginalized identities face overlapping and compounded forms of oppression. Crenshaw, who is credited for the intersectionality theory, presents it from ‘two processes: 1) structural intersectionality or the ways in which systems of inequality co-produce one another to coordinate oppressions and privileges; and 2) political intersectionality, how disadvantaged groups resist their domination through strategies that reflect their intersectional positioning in social hierarchies.’ (Grzanka, 2016). Hill (2017) suggests violence as a crucial entry point to understand intersectionality from the theoretical and political angle. As such we also draw on standpoint theory, that notes knowledge is bounded by social and cultural contexts, and those who are marginalized or oppressed, will have their own unique insights to offer to research findings and knowledge translation.

Hence, by applying intersectional and standpoint lenses, we aimed to anchor “the experiences of individuals who are not members of dominant groups with the goal of opening up different ways of understanding by foregrounding ‘marginalized voices’” (Cabrera et al., 2019; Keeling, 2011; Wigginton & Lafrance, 2019). Additionally, we drew on intersectionality theory by recognizing that the participants of the study, and us as researchers, occupy multiple, intersecting identities and experiences which reflect both marginalization and privilege. We were reflexive in recognizing how our experiences and identities influence what we see and problematize as researchers.

Positioning the Researcher

Study Context

The methodology described in this paper is illustrated through an analysis of open-text responses within the Research Examining Stories of Pregnancy and Childbearing in Canada Today (RESPCCT) study, a community-based participatory action research (CPAR) project. Embedded in social justice and feminist action research frameworks, CPAR is inherently disruptive to traditional research designs by partnering with and centering the “subjects” of research in all stages of study development and implementation (Demange et al., 2012; Israel et al., 1998; Jolivétte, 2015; Reid, 2004). For RESPCCT, this included community collaboration for the conceptualization of the study, co-design and content validation of study measures, participant recruitment and interpretation of results phases.

This cross-sectional study administered via an online survey between 2020–2022 included several open-text options. A total of 6,096 participants from all provinces and territories completed the survey, including people in the following minoritized populations: Indigenous people (First Nations, Metis, Inuit), racialized, sexual and gender minorities, recent immigrants and refugees, people with disabilities, those with history of substance use, incarceration, housing instability, and/or people living in rural or remote areas. Full details of the RESPCCT study development and methodology are available elsewhere (Clark et al., 2022; Vedam et al., 2024).

The RESPCCT study received 2,741 participant’s narratives that were complex, rich and unique in nature, with references to both obstetric violence and respectful maternity care. Conducting arts-based research, through the use of the VCRM, not only enabled us to open up these rich and multilayered narratives; but also supported guided listening, by creating avenues through which we could listen to participants’ multifaceted experiences. To our knowledge, this is the first time VCRM has been used to analyze survey-based open text narrative responses.

Our goal was to present three different poem structures to elicit a range of feelings from the readers. The three types of poems presented in this paper provide researchers with novel means to enhance understanding of the nature of participants’ experiences. In an effort to employ the principles of Critical Feminist Theory, participants’ language was kept intact throughout the analysis and poem generation process. However, the connection to this work and the principles of Critical Arts-Based theory was not made until the completion of the analysis process and the drafting of the findings when the study team discerned that it was reflective of Critical Arts-Based theory (Finley, 2014). This included endeavoring to use participants’ verbatim language in the description of the findings to center participant voices in all stages of the research, and to ensure the language used was accessible to a wide audience.

Data Analysis

The Value of Discomfort in Obstetric Violence Research- a Discussion

Full IPoems have been criticized for reading like a version of the original transcripts (McKenzie, 2021). Additionally, the use of this method with open text survey data here, introduces the risk of not having enough information or rich enough narratives. However, the methodology adapted in our paper, where sentences from each participants’ narrative were used to build the poems, attempts to address these critiques– drawing across narratives and selecting those with rich detail, and combining them in a way that presents the solidarity between survey participants who shared experiences of labour, birthing and obstetric violence. This adaptation of IPoems enabled us to generate poetry from short narratives. We found that using first person voice (e.g., starting each phrase with “I”) is most effective to capture embodied experiences when the participants share their stories, feelings, thoughts and experiences.

Other critiques of this form of arts-based method refer to these poems as ‘found poetry’, because it is created, often in partnership with participants, and requires the use of participants’ unadulterated language or is generated from literature (Butler-Kisber, 2002). However, we consider this to be a strength of this method because it allows for participatory research while ensuring communities access to an art form that is traditionally reserved for the “elite”.

Poet Laureate Billy Collins stated that poetry is ‘an interruption of silence’ (Leavy, 2020) which is appropriate for any form of gender-based violence, in this case obstetric violence, to break the deafening silence around it. Leavy (2020) further uses the term feeling-picture to the generation of poems carefully and artistically selecting words and arranging sentences with purposeful pauses to skillfully present a social issue by creating sensory scenes. During the writing process, we discussed the best order in which to present the poems to most effectively evoke readers’ feelings, and to attempt to comprehend how the poems’ arrangement may influence these feelings. We decided that ordering them by Full-Context-Sparse would preemptively give away the details and full narratives. Conversely, we determined that the opposite approach of Sparse- Context- Full would not have the same impact if the full poem was read last, as a team member stated “It takes the wind out of the full poem”. Thus, we decided that the Sparse-Full-Context order was most appropriate to illustrate the unique impact of each approach. This order creates a level of anticipation, and a desire to know more of the context, without preemptively divulging the plot in the full IPoem, and while the context poem falls last, it can be viewed as a novel iteration.

Although we experimented reading the poems in different orders, we strongly believe that there is no set order in which they should be read. Instead we recommend that the readers attempt to read the poems in multiple different orders; and then listen to them being read aloud, in their own or someone else’s voice, while writing down how each of the ways of listening and reading makes them feel. We acknowledge that no matter what order these poems are read, the reader may feel discomfort. We encourage the readers to engage reflexively with their feelings. Violence research can not only be discomforting but also traumatizing, depending on the intersections of the researchers’ identities, context and embodied experiences. There is potential in this discomfort to move the needle forward in different ways to address an urgent issue, such as obstetric violence, based on how the person sitting with and experiencing the discomfort is willing to move it into action (Chadwick, 2021).

Discomfort has been conceptualized as an epistemic resource for critical feminist research, which can lead to transformative and just research, particularly for obstetric violence (Chadwick, 2021). Furthermore, recent discourses around the effectiveness of trigger warnings deem them as ineffective (Brigland et al., 2023). Sitting with discomfort, and the intense feelings it generates, could be considered a passage to commit to and be accountable to working towards an end. In contrast, ‘methodologies of the privileged’ (Sholock, 2012) feed in, and may enable the sanitization of obstetric violence narratives, such as by referring to obstetric violence as mistreatment.

Researchers have utilized other forms of arts-based knowledge dissemination methods such as an animated film with scripts and narratives created in consultation with the participants on their experience of complications during the perinatal period (Mackintosh et al., 2018). A scoping review of 71 arts-based studies on health research suggested the broadening of arts-based methods and inclusion into qualitative methods which showed a better audience engagement, rich communication and ensured access of the study findings to people beyond academia (Boydell et al., 2012). While sensitive research with arts-based methods may create discomfort in its listeners, audience and stakeholders, this pathway opens up space for critical reflection, interaction and potential pathways for compassionate solutions.

Finally, Gillgan and Eddy (2016) share that the essence of listening requires developing a bond, or trusting relationship with the participants, and that merely engaging in the act of listening is a form of showing respect. Verbal and written communication is more than the use of words. The sound, the tonality, the unsaid, and the hidden references may not be readily comprehensible, but they are all vital to communication. Through multiple listening sessions, VCRM provides opportunities to intentionally identify each of these components by understanding the contrapuntal voices. Chadwick (2021) talks about this multivocality as a result of embodied listenings in her work by presenting the contradictory nature of women’s birthing narratives through two competing voices namely, the restitution voice (sharing everything being fine) and the fleshy voice (showing the problem parts of the experience). In earlier work, the first author (KM) presented contrapuntal voices through a framework (Mayra et al., 2021); and argued that in order for obstetric violence to be addressed through respectful birthing experiences we will need to see a rise in the positive voices, while replacing the negative and neutral voices.

Positioning the Researcher- a Methodologic Strength

Researchers have attempted to reflect on the sensitive nature of conducting obstetric violence research by identifying and declaring their positionality, while being reflexive of how their intersectional identities and experiences influence their standpoint (Niles et al., 2021; Van der Waal et al., 2023). In this paper, we do this for the dual purpose of understanding the particular measures and care needed to ensure that the research process is in tune to participants’ needs, while simultaneously protecting ourselves from the impact of continuous engagement with obstetric violence as it can be isolating and emotionally draining (Boveda & Annamma, 2023; Holmes, 2020; Yip, 2023). We found this to be especially true while engaging with the topic through arts-based research. The literature describes these feelings of isolation as ‘compassion fatigue’ and ‘burnout’, and explain that it may lead to ‘vicarious or secondary trauma’ (Schulz et al., 2022).

I (first author, KM) started seeking sensitive and feminist ways to explore birthing narratives with women after observing obstetric violence in my places of practice as a student nurse-midwife in India, and after facing a language barrier when trying to talk about these embodied experiences of women with traditional research methods. It wasn’t about finding a common tongue but had more to do with the gender and power-based challenges in sharing experiences.

My (BR) career in perinatal health research in the global south has exposed me to various forms of obstetric violence and to the invasive nature of obstetric practice more broadly. It led me to seek out a physiologic birth supported by midwives during my pregnancy. When developing the poem on induction I could easily see loss of agency and power. I had to be aware of my views on obstetric interventions to allow positive narratives to also be elevated.

My (TA) own intersectional identity is what directly shapes my experiences navigating institutions, and created an awareness of how structural power imbalances impact lived experiences from conception. This personal awareness is what led me to Critical Feminist Theory as a framework, through which I can attune myself to themes of institutional power, access, and mistreatment within participant’s narratives.

My (SV) understanding of the power of poetic inquiry to center the authentic voices of underrepresented communities in research, comes from my own lived experiences as a racialized immigrant, parent, and clinician with over 40 years of witnessing these narratives in real time. My undergraduate thesis was a comparison of voices in ancient poetry from my country of origin with the tomes of William Blake, lauded in the western canon. In my experience, VCRM and Ipoems distill and amplify all of those voices in ways that traditional approaches to knowledge translation lose the urgency and import of findings.

Throughout the analysis process we individually and collectively experienced a level of vicarious trauma as a result of the intrinsically sensitive content and explicit descriptions of disrespect, abuse and violence. The first seven months of coding and thematic analysis with the 2,741 participant narratives was particularly isolating for the first author (KM). Furthermore, the vulnerability we experienced was compounded by two factors; a) our intersectional identities and experiences, as we analyzed instances of obstetric and reproductive violence that resemble our experiences, and are relevant to us as a result of our identities within the broader society; and b) our reality of living in, working in, and navigating systems and institutions (Howard & Hammond, 2019). This includes the academic settings in which we conduct our research, that exist within a colonialist white supremist nation, and produce “weathering” (Forrest-Bank, 2016; Geronimus, 1992). We mindfully sought to create a safe and compassionate space for ourselves where our vulnerabilities could be shared, listened to and acknowledged (Page, 2017). This was a key realization and point of reflection throughout the analysis process.

Community Driven Knowledge Translation

We used our vulnerability, produced by our lived experiences and identities, as a means of reducing “researcher blindness”. That is to say, an inability to understand the complexities of participant narratives that may arise as a result of researchers’ position of privilege stemming from their identities, experiences, and existing power dynamics. As researchers we have access to a level of privilege due to our position, supported by a large educational institution. However, as previously discussed, our positionality is informed by our intersectional identities as racialized, migrant women who have given birth, and have navigated reproductive and obstetric health services. This serves to strengthen our analysis and interpretation of the participant narratives.

Arts-based research should not be subjected to the measures of validity that traditional research is judged by (Leavy, 2020; Morris & Paris, 2022). Exercising reflexivity about our positionality throughout, was a critical way to maintain rigour of our research (Massoud, 2022). We had a team member, independent of our study, check five percent of the data against the codebook to maintain inter-coder reliability, in the coding phase of the study. We presented our methods and preliminary iterations at every step to the steering council members, that includes one of our research analysts. We continued our analysis and created further poems after getting the assurance and confidence that the members found this method and adaptation effective, and a community responsive way to tell community stories. Accessibility of the poems are an important quality criterion to evaluate the poems in terms of their clarity of meaning and how available this meaning is to non-academic people (Leavy, 2020). We achieved that by creating the poems from people’s actual voice and regular language. While the language used is directly from the participants, we retained the interpretive control by choosing which sentences would be selected from the data and in what order they would be presented in the poems (Leavy, 2020). Finally, this adaptation of voice centered relational method to create three types of poems with multiple peoples voices presents what Leavy (2020) describes as crystallization, where the meaning of the poems is not only confirmed by the thematic solidarity of these narratives but also the multi-stakeholder steering council whose reaction to these poetry iterations have been strong, palpable, positive and who have been moved and inspired to use them with their illustrations in various knowledge mobilization forms.

During the RESPCCT study’s data collection and analysis process, the research team continuously discussed utilizing arts-based knowledge mobilization ideas to disseminate the study findings. The process included community participants via the study’s Community Steering Council. Community members have strongly endorsed the use of poems as a means of knowledge dissemination. Previous research supports the use and impact of poetic and visual ways of research and knowledge translation (Ludlow, 2014; Mayra, Matthews & Sandall, 2021; Rose, 2016). Thus, we contracted artists to illustrate some of the poems to make it more impactful, and add a visual component. The following illustration (Figure 3) is for the poem ‘I didn’t know I could say no’. The artist had access to the full poem and has previously worked on initiatives on reproductive justice.OPEN IN VIEWER

As obstetric violence researchers, we strongly believe in the power of poetry as a method to draw attention to its extremity and urgency (Bhattacharya, 2013; Chadwick, 2018; McKenzie, 2021). Arts-based knowledge translation allows people to get a better sense of the embodied experiences by helping the audience to achieve a ‘felt-bodily states produce affective’ response (Richardson, 2000). This attempt of generating empathy increases the impact of the research outcome being conveyed. We have noticed this impact first hand, while presenting our findings in meetings and conferences, when the mood of the room is visibly and audibly shifted as a result of sharing participants’ narratives of childbirth. This is particularly true when themes of obstetric violence are shared through different arts-based research outputs, such as birth maps (or body maps), I-poems, birthing stories, or illustrations. Given that the over 6,000 participants from the RESPCCT study not only represent the study population of interest, but also the study’s primary audience and stakeholders, the poems are a sensitive means of presenting the study findings. Finally, we have experienced that when people with power and influence are confronted with narratives of obstetric violence through arts-based research, it can create a level of urgency amongst them and potentially initiate the desired change in perinatal and birthing practices.

We will continue to present these poems in different forms, with illustrations, with voice recorded, and with related art-works to our stakeholders for an impact at all levels, which will continue to include the community members. We have plans to organize events for knowledge mobilization where stakeholders that include community members, policymakers, care providers, midwifery students and clinicians will be invited and the different poems and their illustrations will be shared through poetry reading, and a display of the illustrations.