Autoethnography and Severe Perineal Trauma

An Unexpected Journey From Disembodiment to Embodiment

Holly S. Priddis

Disclosures

BMC Womens Health. 2015;15(88) 

In This Article

Background

Perineal trauma occurs during vaginal birth when injury is sustained to the perineum (the area between the vagina and the anal sphincter). Severe perineal trauma (SPT) is when injury occurs to the perineum with trauma extending to the anal sphincter complex (third degree tear); or a fourth degree tear, this involves injury to the perineum involving the external, internal and epithelium of the anal sphincter.[1] The majority of research on the topic of SPT focuses on risk factors and causes, and the methods of repair to minimise short and long term morbidities.[1–3] Morbidities that can occur following SPT are as a result of damage to the surrounding nerves, disruption of the anal sphincter complex, and extensive scarring of the perineum and anal sphincter. Following SPT, some women remain asymptomatic, whilst other women may experience symptoms including urinary, flatus and faecal incontinence, haemorrhoids, and dyspareunia.[4–6]

In addition to the physical morbidities that women experience as a result of SPT, there is evidence that women may face multiple psychosocial challenges as a consequence of this birth related trauma.[7–9] Studies report experiences of social isolation and marginalisation due to ongoing symptomatology, particularly those symptoms including perineal pain, urinary and faecal incontinence.[10] Previous research has suggested that SPT may also alter a woman's understanding of her identity as a sexual being, as morbidities may affect her ability to engage in sexual activities and as a result impact upon her relationship with her significant other, and her sense of self.[7,8,10] However, despite the impact that SPT has on the physical and emotional wellbeing of women, little research has been undertaken exploring the experiences for women who have sustained SPT. This is concerning given SPT is an increasing reason for litigation in maternity care.[11,12]

I undertook a mixed methods study with the aim to understand the experiences of women who have sustained SPT using a transformative emancipatory framework. The motivation for the research that I undertook for my doctoral research project was health services transformation. My goal was to bring about change in health service provision and care for women who have sustained severe perineal trauma (3rd or 4th degree tears) during childbirth. There were four stages to the mixed methods study: A meta-ethnographic analysis of four qualitative papers reporting on the experiences for women who had sustained a physical postpartum morbidity including SPT;[7] a linked data study which reported upon the risk of recurrence, related morbidities and subsequent mode of birth for women who experienced SPT in NSW between June 2000 and July 2008;[13] in-depth interviews to explore the experiences of women who had sustained SPT;[14] and current service provision in New South Wales from the perspective of Clinical Midwifery Consultants and women.[15] The assumption is that producing evidence and making this available will result in health service transformation.

An Autoethnographic Approach

I took an autoethnographic approach to this study as I had my own experience of a 4th degree tear following the birth of my second baby, and the resulting long term consequences have had a significant impact on my physical and emotional wellbeing. I hoped that by acknowledging the journey of women, and through disseminating my work, I would inspire reflection in health professionals to create change within themselves and the health services within which they work. It has been proposed that a transformative-emancipatory framework is a way of developing a critical investigative research design and advocating for change and challenge social injustices through the research process for marginalised groups.[16,17] It is further influenced by the theoretical lens through which the research is viewed. In this mixed methods study an interpretive feminist lens was used which allowed for the exploration of gender related oppression and marginalisation, valuing the voice of women who described and shared their lived experience of SPT.[14,18] Further, when designing the methods of data collection, consideration should be given to ensuring that the chosen design and analysis process will result in transformation through social change.[17,19,20] In a transformative paradigm, participation of members of the group is valued, to ensure the findings of the research reflect the needs of the community.

When a transformative-emancipatory paradigm is used, the researcher may be a member of the marginalised group as a result of illness, circumstance or from birth. Through my personal experience of SPT I was able to self-identify with the marginalised group under investigation, therefore, I chose to take an autoethnographic approach.

Autoethnography arises from a combination of an autobiographical approach and ethnographic methodology, which focusses specifically on reflexivity and self-consciousness.[21,22] When incorporated into a research project, the experiences of the autoethnographer are considered vital to the data in understanding the marginalised group of which they are a part.[21] Ellis (,[23] p. 10) describes autoethnography as not only a way of knowing about the world, but "has become a way of being in the world, one that requires living consciously, emotionally, and reflexively", and that as autoethnographers we must "…observe ourselves observing, that we interrogate what we think and believe…".

During the conduct of this research and through the process of using an autoethnographic perspective, I did not anticipate that this would result in transformation within myself. I had expected that the research would present personal challenges as I reflected upon my own experience, but I was overwhelmed and unprepared for how confronting this reflection process would be; how emotionally—and consequently—physically challenging this journey would be. Therefore this paper explores the journey of the autoethnographer within this study and the insights gained into this important area of women's health. It further explores the harrowing personal toll, and soul searching, that eventuated along the way for this researcher as a consequence of using an autoethnographic approach. The paper is presented as a multivocal narrative,[24] as woven throughout my words and personal reflections are the stories of the women who participated in this research project. This identifies contrasts and similarities between my story and the stories of other women who have sustained SPT. The quotes that are used are directly from the interviews with the women, those that have been published previously are cited to that publication. Pseudonyms are used to protect the identity of the women.

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