Emotion work among pregnant and birthing women

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Emotion work among pregnant and birthing women Shannon K. Carter Ph.D., Stephanie Gonzalez Guittar Ph.D.

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S0266-6138(14)00125-9 http://dx.doi.org/10.1016/j.midw.2014.05.003 YMIDW1539

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Midwifery

Received date: 9 December 2013 Revised date: 29 April 2014 Accepted date: 4 May 2014 Cite this article as: Shannon K. Carter Ph.D., Stephanie Gonzalez Guittar Ph.D., Emotion work among pregnant and birthing women, Midwifery, http://dx.doi. org/10.1016/j.midw.2014.05.003 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

EMOTION WORK AMONG PREGNANT AND BIRTHING WOMEN Shannon K. Carter, Ph.D.1 Stephanie Gonzalez Guittar, Ph.D.2

Assistant Professor, University of Central Florida, Department of Sociology, 4000 Central Florida Blvd., Orlando, FL 32816-1360. Email: [email protected]. 1

Instructor of Sociology, University of South Carolina Lancaster, Division of Business, Behavioral Sciences, Criminal Justice, and Education, P.O. Box 889, Lancaster, SC 29721. Email: [email protected]

2

EMOTION WORK AMONG PREGNANT AND BIRTHING WOMEN Abstract Background: Previous research has examined emotional labor as an important component of the occupational work of midwives and gynecological nurses. Fewer studies explore emotion work by women during normal pregnancy and birth, and existing studies emphasize emotion work based on the midwifewoman relationship. This study explores use of emotion work during pregnancy and birth among a sample of women. Objective: The study objective is to identify the mechanisms and purposes of emotion work among women during pregnancy and birth. Design: Data consist of 18 in-depth interviews with women regarding their pregnancy and birth experiences and 7 online pregnancy journals. Data were analyzed to identify themes in participants’ descriptions of emotion work during pregnancy and birth. Findings: Participants described four methods of emotion work that included shifting cognitive focus, exerting control, social support and using technology. Participants used emotion work for the four main purposes of maintaining their own and their babies’ health, coping with negative events, managing pain, and achieving their desired birth. Although some emotion work was undertaken in relational context with the midwife or partner, much of the emotion work described took place in solitude. Implications for Practice: Social support from midwives or partners was a form of emotion work that facilitated positive interpretations of the birth experience. Key Words: Emotion work; pregnancy; birth; midwifery

Introduction Recent literature examines emotion management undertaken by midwives in their occupational settings (Deery, 2005, 2009; Deery and Fisher, 2010; Hunter, 2004, 2005, 2006, 2009; Hunter and Deery, 2005). There is less research on emotion work engaged in by pregnant and birthing women, although pregnancy and childbirth are widely acknowledged as emotionally heightened experiences (Author citation; Dixon et al., 2014; John, 2009; Tyrlik et al., 2013). This article examines women’s accounts of emotion work during pregnancy and birth. Hochschild (1979, 1983) contends that emotions are guided by “feeling rules” that delineate expectations for emotional displays in a given social or institutional context. Emotions that conform to feeling rules are often automatic, however when they are not people may engage in “emotion work” – the process of “trying to change in degree or quality an emotion or feeling” (Hochschild, 1979, 561). Emotion work can elicit a desired but absent feeling (“evocation”) or eliminate an undesired but present feeling (“suppression”). It entails “surface acting,” where the individual still feels the socially undesirable emotion but alters the emotional display to hide it, and “deep acting,” where the individual works to actually induce the desired emotion. Emotion work engaged in as part of an occupation is “emotional labor,” which “is sold for a wage and therefore has exchange value” (Hochschild, 1983, 7). We use “emotion work” to refer to emotion management by pregnant and birthing women and “emotional labor” to refer to emotion management by health professionals.  Emotional Labor among Midwives and Related Professionals Emotional labor is a significant aspect of midwives’ work that is often unnoticed and undervalued (Deery and Fisher, 2010; Hunter and Deery, 2005). In western societies, caring is considered “women’s work,” frequently presumed to arise out of women’s biological predisposition to nurture, and therefore is not given adequate recognition or training in caring professions such as midwifery (James, 1989, 1993; Tyler and Taylor, 1998). In training, midwives learn feeling rules and appropriate emotional displays through observation and trial and error (Hunter, 2009). In addition, midwifery’s foundational “with woman” ideology is contradictory to the dominant western “techno-rational” paradigm that requires a “with institution” orientation (Hunter, 2004, 2005; James, 1989). Midwives use emotional labor to manage conflicting ideologies within the healthcare system and to handle ideological and interpersonal conflicts with other midwives (Deery, 2009; Hunter, 2004, 2005). Other structural factors, such as understaffing, heavy workloads, lack of time and devaluation of midwives’ work, are identified as eliciting emotional labor (Deery, 2005, 2009; Deery and Fisher, 2010; Dykes, 2009). Some scenarios can heighten the need for emotional labor, such as working with mothers who fear childbirth (Salomonsson et al., 2010), witnessing births that midwives perceive as traumatic (Rice and Warland, 2013), and experiencing clinical negligence litigation (Robertson and Thomson, 2014). Emotional labor among midwives and other reproductive healthcare providers also entails managing the emotions of women who obtain services. For example, Ruane (1996) identified that social workers and healthcare providers engaged in a “ritual of unbonding” to facilitate appropriate emotional displays by birthing women who give their newborns up for adoption. Techniques included physical separation from other mothers, withholding information about the baby, and allowing women choice in the extent of contact with the baby. Similarly, Bolton (2000) identified substantial emotional labor gynecological nurses performed in the event of late miscarriage – emotion work that she termed a “gift” because it transcends compensated labor – that included honoring the dead baby through rituals of dressing and photographing to help parents through the grief process. An important component of this labor was to “maintain a professional face” despite the nurses’ own emotional grief (Bolton, 2000). The

need to maintain an appropriate emotional display for the circumstances, and therefore “switch and swap faces” (Deery and Fischer, 2010) to support women’s varied situations, is identified as an emotionally draining element of the midwifery profession (Deery and Fischer, 2010; Deery and Kirkham, 2007). Midwives’ emotional labor can also be shaped by the dyadic midwife-woman relationship. Hunter (2006) observed that in “balanced-exchange” women accepted their midwives’ advice which maintained boundaries, was emotionally rewarding, and required no emotional labor. “Unbalanced exchanges,” where women rejected the midwife’s advice (“rejected exchange”), offered advice or support to the midwife (“reversed exchange”), or needed more support than the midwife could give (“unsustainable exchange”) elicited emotional labor. Midwives may also perform emotional labor when working with women who speak a different language, have unique or sensitive situations, or disclose personal histories that contradict the midwife’s values (Deery, 2009). Emotion Work among Pregnant and Birthing Women Previous research has identified that women and their partners engage in emotion work in reproductive healthcare contexts such as abortion, artificial insemination and vaginal ultrasound (Hugill et al., 2013; Ivry and Teman, 2008; Keys, 2010; McCoyd, 2009; Ripper, 2007). Less research explores emotion work by women during normal pregnancy and birth, and existing studies focus on emotion work based on the midwife-woman relationship. Research shows that women experience many emotions throughout birth and use techniques such as remaining calm and offering subtle cues to convey emotional needs to their midwives (John, 2009). Women recognized their need for emotional support from midwives but did not acknowledge this as part of the midwives’ work (John, 2009; John and Parsons, 2006). Among a sample of mothers planning home births, some reported not receiving the emotional support they expected from their midwives, and consequently reduced expectations, relied more on their partners, hid feelings (particularly fear) and some felt the need to compromise their wishes (Edwards, 2009). Evidence suggests women would engage in emotion work not only to manage relationships with midwives but as an integral component of the pregnancy and childbirth process. Pregnancy and birth are widely acknowledged as highly emotional experiences (Author citation; Dixon et al., 2014; John, 2009; Tyrlik et al., 2013). First birth in particular marks a woman’s transition to motherhood, serving as a symbolic “rite of passage” (Davis-Floyd, 1992). Changes in bodily size and shape (Earle, 2003), fear of the childbirth process (John, 2009; Salomonsson et al., 2010) and perceptions of birth as a traumatic event (Beck, 2004; Kitzinger, 2006) are likely to invoke emotion work. John summarized “women experienced wide swings of positive and negative emotion throughout their birth experience” (2009, 637). Research also suggests that pregnancy and birth are guided by feeling rules that define socially appropriate expressions of emotion and pain for expectant mothers. Bone (2009) argues that the way women are supported during birth reflects cultural feeling rules that are sociohistorically situated; in the U.S. today, the dominant form of support is through medical technology (primarily epidural analgesia) rather than interpersonal caring. Concomitantly, women giving birth in U.S. hospitals showed concern over being nice and polite during labor, demonstrating that traditional gender expectations guide appropriate emotional displays during birth (Martin, 2003). These findings were not replicated among U.S. mothers giving birth in out-of-hospital settings, who reported transgressing gender boundaries without remorse, suggesting that institutional settings may impact the feeling rules that guide birth (author citation). The Current Study

Previously, we suggested that emotion work (along with mind work and body work) is a significant component of women’s childbearing experiences (author citation). We found that mothers used emotion work during labor and birth to manage pain and cope with the uncertainty of the birthing process. Because the analysis focused on multiple forms of “work” involved in labor, we did not explore emotion work in depth. The current project isolates emotion work to explore its complexity and responds to a call by Gamble and Creedy that “much more needs to be uncovered about ‘emotion work’ in midwifery to address the needs of childbearing women” (2004, 216). The purpose of this study is to explore the use of emotion work among women during pregnancy and birth. The study expands the literature on emotion work in midwifery by examining emotion work engaged in by women throughout pregnancy and birth. Methodology and Methods Hochschild’s (1979, 1983) theories of emotion management are rooted in the symbolic interactionist tradition in sociology that uses inductive, qualitative methodology. Symbolic interactionism posits that individuals act on the basis of symbolic meanings that are derived through social interaction and interpretive process (Blumer, 1969). That is, things are not intrinsically meaningful, but rather, humans attribute meanings to things based on their interactions with others and their own interpretations of those interactions (Blumer). Symbolic interactionist research relies on qualitative methodologies to uncover similarities and variations in people’s subjective interpretations of different phenomena (Denzin, 1978). The current study uses qualitative accounts of pregnancy and childbirth to analyze the symbolic interpretations of emotions that arise throughout the narratives and mothers’ accounts of their own emotion management. Data were derived from in-depth interviews with mothers who had recently given birth and online pregnancy journals. Interview participants were recruited through personal and professional contacts. To be eligible, participants needed to be age 18 or older and have a child under 18 months old. Participants referred individuals in their network who met the study criteria, resulting in a “snowball” sample (Noy, 2008). Informed consent was obtained prior to each interview. Participants’ names were changed to pseudonyms that they provided. The interview study was approved by the University of Florida Institutional Review Board. The interview sample consisted of 18 predominantly white, middle-class mothers residing in the U.S. Participants ranged in age from 24-49 years with a median age of 29. Most (72%) were first-time mothers, 22% had given birth to a previous child and one had become a mother through adoption before giving birth to a subsequent child. Ten participants chose an obstetrician/gynecologist as their care provider, gave birth in a hospital and received some form of anesthetic pain management. Of the remaining eight participants who gave birth with midwives, three gave birth at home, two at free-standing birth centers, two at hospitals, and one labored at a birth center and transferred to a hospital. Participants engaged in in-depth interviews that ranged from 45 to 120 minutes that asked questions about their experiences of pregnancy, labor, birth, and early postpartum. Interviews were conducted face-to-face by the first author at the participant’s or the researcher’s home. Interviews were audio-recorded and transcribed verbatim by the first author for analysis. Interviews were supplemented with seven pregnancy journals posted online. The journals were week-by-week accounts of the pregnancy experience that were voluntarily posted by the authors on a public, open access website. Journals were identified as a potential data source when they were read out of personal interest during the first author’s pregnancy. Journals were included as data for the study because the themes identified in the journals paralleled the interview data, but often provided more

thorough descriptions of emotional experiences and methods for managing emotions. Unlike the interview data, where participants gave a retrospective account of their experience, the pregnancy journals were updated weekly to represent the author’s current experience. Seven journals were selected from a popular U.S.-based pregnancy and childbirth website based on convenience (most recent at the time of the reading) and completion (including the birth story). Since the stories were written by the women for their personal purposes, these data were not biased by the research process. According to Jones and Alony (2008), online data from voluntary sources offer “a level of reliability which is not greatly different than other methods of data collection.” Analysis of stories published on the internet does not constitute human subjects research because there is no interaction with a human subject or collection of “identifiable private information” (Kraut et al., 2004). Further, there is no “expectation of privacy” since the journals were published on an open access website for public readership (Kraut et al.). Nevertheless, pseudonyms were applied by the researchers to protect anonymity (Sixsmith and Murray, 2001). Initial coding (Charmaz, 2000) entailed identifying excerpts in the narratives where participants described engaging in emotion work, specifically, trying to induce or suppress a particular emotion. These excerpts were selected out of the transcripts and compiled into a single document where they could be further analyzed. We then performed focused coding (Charmaz, 2000) by reading each excerpt to identify similarities and differences in how women talked about emotion work. Each author independently analyzed the data and discussed their insights. Two main themes emerged from the analysis: purposes of emotion work and methods of emotion work. Data were then classified into these two broad categories and further analyzed for similarities and differences. Four themes were identified in each category. Excerpts were selected that best represent each theme. The methodological orientation of naturalism guided this study, as we assume that women’s accounts of their experiences represent a reasonable approximation of their lived experience (Gubrium and Holstein, 1997; Plummer, 2001). Naturalism is the best methodological orientation for this study as it corresponds with symbolic interactionism (Gubrium and Holstein, 1997), the theoretical orientation from which Hochschild’s theory of emotion work is derived. Findings The two main themes that emerged are methods and purposes of emotion work. Methods of emotion work were the activities women engaged in to manage their emotions whereas purposes of emotion work were the intended outcomes of emotion management. [Table about here] Methods of Emotion Work Participants described four methods of emotion work: shifting cognitive focus, exerting control, social support and using technology. The first method, shifting cognitive focus, is the attempt to alter one’s emotional state by diverting attention away from the negative stimulus toward something else. Shifting cognitive focus is akin to the process of “deep acting” described by Hochschild (1983) whereby an individual uses thought to mentally induce an emotion that is then physically manifest in the body. For women in this sample, staying busy allowed them to divert cognitive focus away from the emotion toward something else, inducing a different emotion. This technique was often used to cope with disappointment from pregnancy lasting beyond the “due date.” My due date … was May 23. … May 23 came and went and I remember crying that day because I thought I was magically going to go into labor. I was already on maternity leave so I tried to keep myself busy but it was difficult. (Jackie, online pregnancy journal)

My body is still getting ready, for the Braxton-Hicks haven't let up any…. I am bound and determined not to be the mental basket case I have been with the other pregnancies. It is helping that school is still going on and that helps to keep my mind occupied these last few weeks when historically I've mentally gone downhill. I have also conditioned myself throughout the whole 37 weeks thus far that this pregnancy will go past the due date. I'm not paying attention to the due date(s) and I'm telling myself that it will probably be around October 17 (that's also what I'm telling other people, so that is helping as well). … But I also have a peace and calmness within me that is new and boy, is that a good feeling!! (Brielle, online pregnancy journal) Participants described shifting cognitive focus as a method of emotion management by “keeping busy,” “keeping the mind occupied,” and “conditioning” themselves. By focusing the mind on something other than the upsetting stimulus, participants demonstrated some ability to exert control over their emotions. Shifting cognitive focus entailed managing others’ access to information, particularly the “due date.” Participants reported lying about their due dates as a precautionary measure to avoid unwanted attention from friends and family that would inhibit their abilities to divert attention away from it. The second method of emotion work was exerting control, particularly by making efforts to control the situation. Participants attempted to control the situation by selecting specific healthcare providers, choosing the location for labor and delivery, and writing a birth plan. By taking control over the birth environment, participants tried to minimize the potential for undesired stimuli that could generate negative emotions. The biggest reason I wanted to give birth at the birth center was because I didn’t want to be separated from my baby. My sister gave birth in a hospital and they took her baby away for like two days. That would be the worst thing for me. I don’t think I’d be able to handle it. (Cindy, interview) This participant reports selecting her birth location to control potential separation of herself from her baby, which she predicts would elicit a negative emotion. This method of emotion management is a preventative approach, where precautionary measures are taken to avoid a situation that could result in a negative emotional reaction. Participants also controlled access to information to manage their emotions. They controlled information by determining when to obtain health care – either “putting it off” until they felt ready to manage the information they might obtain or making an appointment to speed access to knowledge – or obtaining their own medical devices to obtain information. I'd been feeling a little wiped out from the sadness of losing a twin, the guilt of being too tired to get things done, and the fear and stress of getting this baby through the first trimester. I was too irritable to talk on the phone, answer emails, or go out with friends. I wanted to climb into bed and disappear at least until the very dangerous first trimester was over. But my magical relief arrived in the mail this week. The Doppler I rented online is finally here! It's amazing to hear first my own slow pulse then that quick little baby's heartbeat thumping away! (Alyssa, online pregnancy journal) By controlling information participants manage the possibility of encountering a stimulus that could produce a negative emotion. Some avoided healthcare until they felt prepared to handle their potential emotional response whereas others sought healthcare quickly to obtain information they hoped would generate a positive emotion. In this way, controlling information was a mechanism of emotion management.

The third method of emotion work was social support, relying on others to help with relaxation and sharing emotions with others. Finally a nurse came in to check me since I was so uncomfortable. She checked and to all of our surprise … I was fully dilated! I was actually so relieved that I started crying. The nurse and Steven calmed me, got me into the wheelchair, and wheeled me back to the room. (Alisha, online pregnancy journal) This participant reports that the nurse and her partner “calmed” her. Here emotion work is a social effort, where others interact with the woman to help manage her emotions. Mechanisms for emotion management through social support included verbal encouragement, breathing together, and physical contact such as a hug or massage. Kara described using social support to manage her emotions, but the mechanism differs in that she felt comforted by sharing emotions with her partner. I had worked myself into a panic and was on my way to the hospital having convinced my poor husband that something was terribly wrong. As I sat in the hallway waiting for a sonogram machine to become available, watching him pace back and forth, I realized how worried and nervous he was too and while part of me wished I could avoid burdening him with it mostly I was relieved to have someone to share my anxiety with. (Kara, online pregnancy journal) Kara reports feeling relieved by seeing the emotion she was experiencing manifest in her partner, illustrating the concept of managing emotions by sharing them collectively. Observing the emotion manifest in a significant other brought comfort, aiding her emotion management. The fourth method of emotion work was using technology to manage emotions. Participants used technology as a mechanism for providing information about the health status of themselves and their babies. This is discussed above under the category of control, but it overlaps in that technology was typically the mechanism through which knowledge was acquired; access to knowledge was controlled by controlling access to technology. Technology was also important to those who opted for pharmacological pain relief during labor and delivery as a method of managing emotions. After the epidural I did not feel the contractions at all. … It took the anxiety away. I had been so anxious to move on. … I was waiting for the next contraction because I was wanting it. I was thinking that if I had more contractions and harder contractions that I was moving farther along on the centimeters, which isn’t necessarily true. But after they gave me the epidural I didn’t focus on that anymore. … Basically my energy was now on relaxing instead of being so obsessed with breathing through the next contraction. (Elizabeth, interview) Several participants described a shift in their emotional state after receiving epidural anesthesia. They reported feeling more relaxed and ready to manage the remainder of the labor and birth process. Purposes of emotion work Emotion work served four main purposes for study participants: maintaining health, coping with negative events, managing pain, and achieving their desired birth. In the first theme, maintaining health, participants described managing emotions to maintain or create a healthy pregnancy. Some described managing emotions as a way of “passing” clinical tests. This week … all the tests for my pre-eclampsia came back negative! Phew! When I went to see my midwife, I made sure to leave in plenty of time so I wouldn’t feel stressed when they took my blood pressure reading. (Jaime, online pregnancy journal)

Participants worked to control their situations or their responses to situations in attempt to maintain a state of calm that would reflect in the clinical tests. Here emotion work is used to attempt to maintain health, or at least maintain an appearance of health. A few participants who had particularly stressful situations during pregnancy perceived their lack of emotion work as having negative consequences for their babies. Cindy believed the stress of her marriage caused her baby to be born three weeks early. She explained: Just keeping calm has everything to do with happy, healthy babies. And I wasn’t calm at the time, I was feeling stressed out. And I feel like that caused things to happen that didn’t need to happen. I felt like the feelings of a woman while she is pregnant I think greatly influence the type of baby you will have, what their personality is going to be like and whether they’ll be high strung, whether they will be more relaxed, things like that. And I felt like the more relaxed I was the more likely I was to have a healthy baby and a healthy mind. (interview) In this narrative, emotion work is perceived as an important aspect of attempting to maintain maternal and infant health, as negative emotions are perceived as having negative health consequences. The second theme, coping with negative events, entailed engaging in emotion work as a way of dealing with negative events or information. For example, Nancy planned a homebirth, but at 43 weeks it was determined that she would require a hospital induction. My next entry will be my birth story. It won’t have the ending I’ve been dreaming of for months now. But, considering my situation, it is for the best. … I’m not sure how long the process will take or how it will turn out, but the end is in sight and when I start to get sad about how things have turned out I boost my spirits with that. (online pregnancy journal) Participants described working to manage emotions after hearing news of pregnancy loss, continuing pregnancy beyond the due date or coping with undesired changes in the birth plan. In this theme, emotion work is used to deal with negative or disappointing news or events. The third theme, managing pain, entailed controlling emotions as a way of coping with pain. Participants described using emotion work as pain management when dealing with common discomforts of pregnancy, and pain from labor contractions or medical procedures. Clarisse described using emotion management during her 20 week ultrasound: The tech wasn't getting good pictures for her liking, so there I was, flat on my back for the whole time. I was quite uncomfortable. … There were several times she was pressing so hard into my stomach that I had to ask her to let up some. But, I kept looking at the monitor and was telling myself that the brief pain and discomfort was worth it. And I got through it. (online pregnancy journal) Clarisse described using her thoughts to manage her emotional response to the bodily discomfort she experienced, which helped her manage pain during an ultrasound. Liz described feeling irritable during labor before experiencing a change once she shifted her cognitive focus from feelings of irritation to physical sensations within her body: Looking back I think this must have been transition. I still didn't have any pain but I became very irritated. The urge to pee was so strong and coming and going at very regular intervals. I was sick of asking to get up and of trying to relax enough to go in a bedpan in the bed. If they wouldn't let me go to the bathroom, I'd just go right here all over the bed and that nurse would just have to come in and clean it up and I wouldn't care one bit! I also wished they would turn off the TV and the sound on the monitors. All that beeping and thump-thumping and talking was getting on my last nerve. How could [my husband] have just left me here all by myself? And that's

when it hit me. Maybe the nurse was right. I started to concentrate through each contraction and the more I allowed my body to relax, the more bearable the pressure became. I quickly found a rhythm of feeling the pressure build, allowing every part of my body to let go, and resting in between. (online pregnancy journal) Liz’s narrative describes a shift in focus from the external stimuli that heightened her irritation to the physical sensations within her body. As she turns her mind from the external sources of irritation to the processes occurring within her body she is able to manage the pain she associates with labor contractions. This emotion management becomes a technique of managing pain. The fourth theme, achieving their desired birth, entailed using emotion management to try to accomplish a desired birth process and outcome. Participants described using the form of emotion work Hochschild (1979) identifies as “suppression,” the elimination of an undesired feeling, to try to eradicate feelings of fear surrounding the labor and delivery process. [The birth] was intense. I didn’t let myself be afraid. I didn’t let myself be afraid before because I knew I wanted to have a natural childbirth and I didn’t want to let fear into me. That can be one of the worst things about the birth is being afraid. (Samantha, interview) In this theme participants described engaging in suppression to disallow emotions – particularly fear – from interfering with their desired birth. Thus emotion management is used as a mechanism to try to achieve a particular type of birth (e.g., unmedicated or vaginal). Discussion This study contributes to literature on emotion work in midwifery by illustrating that pregnant and birthing women engage in emotion management and identifying some of the methods and purposes of it. Participants described four methods of emotion work that included shifting cognitive focus, exerting control, social support and using technology. They used emotion work for the purposes of maintaining health, coping with negative events, managing pain, and achieving their desired birth. Previous research has focused on emotional labor in occupational settings among midwives (Deery, 2005, 2009; Deery and Fisher, 2010; Hunter, 2004, 2005, 2006, 2009; Hunter and Deery, 2005) and gynecological nurses (Allan and Barbar, 2005; Bolton, 2000, 2005; Lipp and Fathergill, 2009; McCreight, 2005). Fewer studies have examined emotion work undertaken by pregnant and birthing women, and they emphasize women’s emotion work in the context of the midwife-woman relationship (Edwards, 2009; John, 2009; John and Parsons, 2006). Our study contributes to this body of literature by focusing on emotion work performed by women throughout pregnancy and birth, much of which occurs independent of the woman’s relationship with her midwife. Women described some emotion work taking place in solitude and resulting from health concerns or other stimuli related specifically to pregnancy and birth. Combined with past research, a complicated picture emerges where midwives may engage in emotional labor to manage heavy caseloads, ideological conflicts and other aspects the profession, women may engage in emotion work to manage fear, pain and other aspects of pregnancy and birth, and the two may engage in emotion work to manage their relationships with each other. Although beyond the scope of the this study, this finding might also apply to women’s partners and significant others as research demonstrates that partners engage in emotion work to manage responses to aspects of pregnancy and birth (Hugill et al., 2013; Ivry and Teman, 2008) and some participants in the current study reported that their relationships and interactions with their partners elicited emotion work. Each individual involved in the pregnancy/birth could potentially engage in emotion work to manage their own responses to stimuli as well as their relationships and unfolding interactions with each other.

Not only are emotions managed as a result of social interactions (Hunter, 2005, 2006; James, 1989; John, 2009), but in the current study emotions were shown to be managed through social interactions. Participants described using social support, such as talk or touch, as a method of emotion management. They reported improved affect when a healthcare provider or partner assisted them in emotion work or when they felt able to “share” emotions with partners and observe their partners’ emotional display. Thus, relationships and interactions are not only stimuli that elicit emotion management but can also serve as methods of emotion work. Our findings illuminate two significant uses of technology in relation to emotions. Some participants managed emotions by controlling access to information, often involving technology. Whereas some avoided interaction with technology (and correspondingly, their midwives) until they were emotionally prepared for information they would gain, others sought technology to verify health status. In both cases, knowledge gained through technological means was considered “authoritative knowledge” (Jordan, 1993), deemed superior and more factual than knowledge acquired through any other source. Participants managed emotions by controlling access to the authoritative knowledge they believed technology would provide. A second use of technology was identified wherein some participants alluded to use of epidural analgesia as a form of emotion management by describing emotional rather than physical changes after receiving it. This finding resembles the observation by Dixon et al. (2014) that women’s birth narratives are predominantly stories of emotions, and corroborates the social science perspective that pain is not only a physical sensation but also encompasses emotions and cultural meanings (Morris, 1994; ScheperHughes and Lock, 1987; Williams and Bendelow, 1996). Viewed as an emotional and cultural experience, a culturally-prescribed method of pain management can also be viewed as a form of emotion management. This finding compliments Bone’s (2009) contention that in U.S. maternity care, “therapeutic emotional labor” is replaced with medical technologies such as epidurals and cesarean births. Whereas birth attendants in the past worked with mothers to transform emotions of fear into courage, the capitalist drive to increase profits has created a “care deficit” (Hochschild, 2003), reducing nurses abilities to provide emotional support (Bone, 2009). In this absence, mothers rely on epidurals for pain management, further directing maternity nurses’ attention toward technological interventions and away from interactional support (Bone, 2009). Our study corroborates Bone’s assertions by illustrating women’s use of epidurals as a technique of emotional management. In lieu of sufficient social support to manage emotions and pain, women in our study turned to technological interventions. Study findings revealed that women engage in emotion work not only to conform to the socially prescribed feeling rules (Hochschild, 1979, 1983) or to manage relationships with their midwives as past research has identified (Edwards, 2009; John, 2009; John and Parsons, 2006), but also as a matter of managing their health. In particular, women used emotion work as a way of shaping the health status of themselves and their babies, and interpreted emotion work (or a lack thereof) as a cause of positive or negative health outcomes. Women used emotion work to manage their health status or its appearance to facilitate their ability to give birth in the desired manner, whether out of hospital or without certain medical technologies. This result is consistent with Edwards’ (2009) finding that women disengaged from their midwives and managed emotional displays to hide feelings, particularly fear or need for social support. Women in both studies used emotion work to manipulate perceptions of their physical and emotional status to ensure their midwives would not disrupt their birthing intentions. In the current study, women demonstrated belief that emotion work not only managed their outward display, but that it significantly impacted their health status. Therefore, emotion work can be engaged in not only for the

purpose of managing impressions in social interactions, but on the belief that it can change one’s physical state for their own wellbeing. In the case of pregnancy and birth this is extended to include the health and wellbeing of the baby. In some ways women’s emotion work can be viewed as expressions of agency in the pregnancy and childbirth process. Participants saw themselves as active agents of their health and used emotion work to achieve positive experiences and health outcomes as well as cope with negative news or events. Some viewed emotion work as a tool that enabled them to give birth in out-of-hospital settings and without unwanted medical technologies. As such, engaging in emotion work could be viewed as an empowering tool for pregnant and birthing women. However, pregnancy and birth in the U.S. are dominated by a “techno-rational” paradigm that relies on scientific medicine, advanced technologies and bureaucratic authority to manage the pregnant and birthing body (Davis-Floyd, 1992; Martin, 1992; Simonds et al., 2007). This approach is identified as disempowering to women, as it strips them of personhood by separating body from self and limits decision-making power regarding use of technological interventions and mother-baby separation (Davis-Floyd, 1992; Martin, 1992; Simonds et al., 2007). Some women used emotion work to limit their engagement with the techno-rational paradigm yet they were prohibited from engaging in a full expression of agency because its potential infiltration was omnipresent. Women knew the requirement to transfer care to a medical doctor and give birth in a hospital, potentially with procedures they strongly wished to avoid, was always a possibility if certain risks became apparent or if labor did not progress. Women also believed their physical health and emotional states could significantly impact the health and wellbeing of their babies, and therefore believed they needed to engage in emotion work to protect their babies from negative outcomes. Therefore, while emotion work may serve as a source of agency that women can use to manage stressful situations and achieve their desired birth, the need to engage in emotion work in order to have an empowering birth and conform to social standards of “good mothering” could also be viewed as a form of oppression. Understanding emotion work during labor and birth has implications for midwifery practice. The findings show that women engage in emotion work as part of the pregnancy and birth process. Social support from midwives or partners was a form of emotion work that facilitated positive interpretations of the birth experience, which is related to birth outcomes. Greater emotional stability and lower levels of anxiety during pregnancy increase the likelihood of normal birth whereas increased anxiety is associated with complications and poorer fetal outcomes (Hernandez-Martinez et al., 2011). Emotional stability during pregnancy and birth is related to the social support women receive (Lundgren and Dahlberg, 1997; Tyrlik et al., 2013) and women’s birth satisfaction is most impacted by social aspects of the experience (Campero et al., 1998; Fowles, 1998; Rudolfsdottir, 2000). Thus, guidance in emotion management may substantially impact women’s retrospective evaluations of their birth experiences. In professional settings where emotional guidance by midwives is not possible due to heavy caseloads (Deery, 2006; Deery and Fisher, 2010), lack of time (Dykes, 2009), or the midwife-woman relationship (Hunter, 2006), support training for significant others through childbirth education classes or recommendations for doula support may help women have their emotional needs met. This study is limited by its small sample size and therefore is not intended to be generalizable. Study participants were predominantly white, middle-class mothers in the U.S., limiting the representativeness of the sample. Future research on emotion work among women during childbearing should focus on diverse groups of women to identify racial, ethnic, religious and social class particularities regarding the methods and purposes of emotion work. In addition, cross-cultural

comparison may illuminate cultural specificity of feeling rules that guide pregnancy and birth and techniques for emotion management. Our two data sources – pregnancy journals and in-depth interviews – provided a starting point for understanding emotion work among mothers during pregnancy and birth however the data could be strengthened by a longitudinal approach that combines both forms of data collection with each participant. We believe the weekly record created by pregnancy journals allowed for more “raw” accounts of emotions that were experienced by participants at the time the accounts were written. The in-depth interviews offered the opportunity for the researcher to probe participants to provide deeper descriptions of their experiences, but were limited because they were retrospective. An approach for future research that combines weekly pregnancy journals and in-depth interviews to discuss and expand upon experiences recorded in journals may generate particularly rich data on women’s emotional experiences. Conflicts of Interest There are no conflicts of interest for the authors of this research.

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Table: Methods and Purposes of Emotion Work  Methods of Emotion Work  Shifting Cognitive Focus  Exerting Control  Social Support  Using Technology   

Purposes of Emotion Work  Maintaining Health   Coping with Negative Events  Managing Pain   Achieving their Desired Birth

Acknowledgements We wish to thank the women who participated in this study for sharing their personal experiences.  

Highlights • Women in the study engaged in emotion work as part of the pregnancy and birth process • Methods of emotion work identified were shifting cognitive focus, exerting control, social support and using technology • Emotion work was used to attempt to maintain health, cope with negative events, manage pain and achieve the desired birth